Provider Demographics
NPI:1235863978
Name:LAKE MICHIGAN DERMATOLOGY PLLC
Entity Type:Organization
Organization Name:LAKE MICHIGAN DERMATOLOGY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER, OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:BERGER
Authorized Official - Suffix:
Authorized Official - Credentials:MD MPH
Authorized Official - Phone:616-499-4844
Mailing Address - Street 1:1148 WASHINGTON AVE STE 20
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-7728
Mailing Address - Country:US
Mailing Address - Phone:616-499-4844
Mailing Address - Fax:269-849-8708
Practice Address - Street 1:1148 WASHINGTON AVE STE 20
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-7728
Practice Address - Country:US
Practice Address - Phone:616-499-4844
Practice Address - Fax:616-499-4847
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-10
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty