Provider Demographics
NPI:1588019053
Name:LEGACY DERMATOLOGY GROUP PC
Entity Type:Organization
Organization Name:LEGACY DERMATOLOGY GROUP PC
Other - Org Name:LEGACY DERMATOLOGY GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:LEGACY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:248-338-6400
Mailing Address - Street 1:1392 S CASS LAKE RD
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48328
Mailing Address - Country:US
Mailing Address - Phone:248-338-6400
Mailing Address - Fax:248-338-2920
Practice Address - Street 1:1392 S CASS LAKE RD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48328
Practice Address - Country:US
Practice Address - Phone:248-338-6400
Practice Address - Fax:248-338-2920
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-03
Last Update Date:2020-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101017676207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty