Provider Demographics
NPI:1306011887
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:248-969-8600
Mailing Address - Street 1:51 S WASHINGTON ST
Mailing Address - Street 2:SUITE G
Mailing Address - City:OXFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48371-6418
Mailing Address - Country:US
Mailing Address - Phone:586-969-8600
Mailing Address - Fax:586-997-9738
Practice Address - Street 1:51 S WASHINGTON ST
Practice Address - Street 2:SUITE G
Practice Address - City:OXFORD
Practice Address - State:MI
Practice Address - Zip Code:48371-6418
Practice Address - Country:US
Practice Address - Phone:586-969-8600
Practice Address - Fax:586-997-9738
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-25
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI058522207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N99670Medicare PIN