Provider Demographics
NPI:1376765560
Name:ANN ARBOR DERMATOLOGY CLINIC PC
Entity Type:Organization
Organization Name:ANN ARBOR DERMATOLOGY CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALBERT
Authorized Official - Middle Name:CRAIG
Authorized Official - Last Name:CATTELL
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:734-996-8757
Mailing Address - Street 1:706 W HURON ST
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-4212
Mailing Address - Country:US
Mailing Address - Phone:734-996-8757
Mailing Address - Fax:734-996-8767
Practice Address - Street 1:706 W HURON ST
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-4212
Practice Address - Country:US
Practice Address - Phone:734-996-8757
Practice Address - Fax:734-996-8767
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301036627174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0H11070OtherBLUE CROSS BLUE SHIELD #
MI1422078-10Medicaid
DF9791OtherPALMETTO GBA
0M74520Medicare PIN
MI0N96800Medicare PIN
MI1422078-10Medicaid