Provider Demographics
NPI:1225218076
Name:MICHAEL R COHEN, DO, PLLC
Entity Type:Organization
Organization Name:MICHAEL R COHEN, DO, PLLC
Other - Org Name:GREAT LAKES DERMATOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:RANDY
Authorized Official - Last Name:COHEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:248-259-7733
Mailing Address - Street 1:6773 OYSTER CV
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48323-2050
Mailing Address - Country:US
Mailing Address - Phone:248-259-7733
Mailing Address - Fax:
Practice Address - Street 1:39475 LEWIS DR
Practice Address - Street 2:SUITE 150
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48377-2981
Practice Address - Country:US
Practice Address - Phone:248-324-2222
Practice Address - Fax:248-324-0009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-09
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101014034207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIDE3321OtherMEDICARE RAILROAD CARRIER
MI0P10570Medicare PIN