Provider Demographics
NPI:1407233323
Name:SOUTH LYON DERMATOLOGY, PC
Entity Type:Organization
Organization Name:SOUTH LYON DERMATOLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED REP/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:M
Authorized Official - Last Name:CLAY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:248-479-2200
Mailing Address - Street 1:26036 PONTIAC TRL
Mailing Address - Street 2:
Mailing Address - City:SOUTH LYON
Mailing Address - State:MI
Mailing Address - Zip Code:48178-8050
Mailing Address - Country:US
Mailing Address - Phone:248-479-2200
Mailing Address - Fax:248-479-2682
Practice Address - Street 1:26036 PONTIAC TRL
Practice Address - Street 2:
Practice Address - City:SOUTH LYON
Practice Address - State:MI
Practice Address - Zip Code:48178-8050
Practice Address - Country:US
Practice Address - Phone:248-479-2200
Practice Address - Fax:248-479-2682
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-29
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1407233323Medicaid
MIMI8758Medicare PIN