Provider Demographics
NPI:1346457488
Name:NORTHWESTERN MICHIGAN DERMATOLOGY
Entity Type:Organization
Organization Name:NORTHWESTERN MICHIGAN DERMATOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SOUMIT
Authorized Official - Middle Name:SHAM
Authorized Official - Last Name:PENDHARKAR
Authorized Official - Suffix:
Authorized Official - Credentials:MHA
Authorized Official - Phone:231-935-8717
Mailing Address - Street 1:550 MUNSON AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-3580
Mailing Address - Country:US
Mailing Address - Phone:231-935-8717
Mailing Address - Fax:231-935-9230
Practice Address - Street 1:550 MUNSON AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-3580
Practice Address - Country:US
Practice Address - Phone:231-935-8717
Practice Address - Fax:231-935-9230
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1962511097OtherNPI
MI1285743393OtherNPI
MI4301063462OtherMI LICENSE
MI4301077553OtherMI LICENSE
MI1437268661OtherNPI
MI4301406284OtherMICHIGAN LICENSE
MI1770692873OtherNPI NUMBER
MI1997138Medicaid
MI3347473Medicaid
MI4301067697OtherMI LICENSE
MI4317989Medicaid
MI1285743393OtherNPI
MI4301063462OtherMI LICENSE
MI1770692873OtherNPI NUMBER
MIG95099Medicare UPIN