Provider Demographics
NPI:1417442898
Name:CONCIERGE DERMATOLOGY & SKIN SURGERY CENTER
Entity Type:Organization
Organization Name:CONCIERGE DERMATOLOGY & SKIN SURGERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:MERCY
Authorized Official - Middle Name:A
Authorized Official - Last Name:ODUEYUNGBO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:906-362-7546
Mailing Address - Street 1:540 S LAKESHORE BLVD UNIT 34
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-4631
Mailing Address - Country:US
Mailing Address - Phone:708-833-9990
Mailing Address - Fax:
Practice Address - Street 1:500 CAMPUS DR
Practice Address - Street 2:
Practice Address - City:HANCOCK
Practice Address - State:MI
Practice Address - Zip Code:49930
Practice Address - Country:US
Practice Address - Phone:906-362-7546
Practice Address - Fax:413-269-8079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-27
Last Update Date:2018-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI207ND0101X, 207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty