Provider Demographics
NPI:1467454264
Name:AFFILIATED TROY DERMATOLOGISTS, PLLC
Entity Type:Organization
Organization Name:AFFILIATED TROY DERMATOLOGISTS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:DR
Authorized Official - First Name:MARCIA
Authorized Official - Middle Name:BROOKS
Authorized Official - Last Name:CARDELLI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-267-5020
Mailing Address - Street 1:4600 INVESTMENT DR
Mailing Address - Street 2:STE 260
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48098-6365
Mailing Address - Country:US
Mailing Address - Phone:248-267-5020
Mailing Address - Fax:248-267-5021
Practice Address - Street 1:4600 INVESTMENT DR
Practice Address - Street 2:STE 260
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48098-6365
Practice Address - Country:US
Practice Address - Phone:248-267-5020
Practice Address - Fax:248-267-5021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-11
Last Update Date:2015-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI405985174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIE64353Medicare UPIN
MIB44451Medicare UPIN
MIH32955Medicare UPIN