Provider Demographics
NPI:1265645535
Name:ACADEMIC DERMATOLOGY & COSMETIC SURGERY CENTER, PLLC
Entity Type:Organization
Organization Name:ACADEMIC DERMATOLOGY & COSMETIC SURGERY CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:G
Authorized Official - Last Name:SANDLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-997-9700
Mailing Address - Street 1:51189 SHELBY PKWY
Mailing Address - Street 2:
Mailing Address - City:SHELBY TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48315-1786
Mailing Address - Country:US
Mailing Address - Phone:586-997-9700
Mailing Address - Fax:586-997-9738
Practice Address - Street 1:50182 SCHOENHERR ROAD
Practice Address - Street 2:
Practice Address - City:SHELBY TWP.
Practice Address - State:MI
Practice Address - Zip Code:48315
Practice Address - Country:US
Practice Address - Phone:586-997-9700
Practice Address - Fax:586-997-9738
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301058522207N00000X, 207ND0101X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N99670Medicare PIN
MION99670Medicare PIN
MIG15362Medicare UPIN