Provider Demographics
NPI:1417058116
Name:DERMATOLOGY ASSOC OF MACOMB OAKLAND PC
Entity Type:Organization
Organization Name:DERMATOLOGY ASSOC OF MACOMB OAKLAND PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:KAUFMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-751-2520
Mailing Address - Street 1:11250 E 13 MILE RD
Mailing Address - Street 2:STE 2B
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-2597
Mailing Address - Country:US
Mailing Address - Phone:586-751-2520
Mailing Address - Fax:586-751-7004
Practice Address - Street 1:11250 E 13 MILE RD
Practice Address - Street 2:STE 2B
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-2597
Practice Address - Country:US
Practice Address - Phone:586-751-2520
Practice Address - Fax:586-751-7004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2013-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI070E060680OtherBCBSM
MI070E060680OtherBCBSM