Provider Demographics
NPI:1144618075
Name:DEROSA PLASTIC SURGERY, PLLC
Entity Type:Organization
Organization Name:DEROSA PLASTIC SURGERY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AMY
Authorized Official - Middle Name:P
Authorized Official - Last Name:DEROSA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:248-688-7597
Mailing Address - Street 1:22401 FOSTER WINTER DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-3724
Mailing Address - Country:US
Mailing Address - Phone:248-688-7597
Mailing Address - Fax:248-498-6060
Practice Address - Street 1:22401 FOSTER WINTER DR
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-3724
Practice Address - Country:US
Practice Address - Phone:248-688-7597
Practice Address - Fax:248-498-6060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-30
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010170432086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI7789986Medicaid