Provider Demographics
NPI:1598959603
Name:THE SKIN CANCER CENTER OF SE MICHIGAN PC
Entity Type:Organization
Organization Name:THE SKIN CANCER CENTER OF SE MICHIGAN PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:STIFF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-355-5047
Mailing Address - Street 1:26400 W 12 MILE RD
Mailing Address - Street 2:SUITE 180
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-1700
Mailing Address - Country:US
Mailing Address - Phone:248-355-5047
Mailing Address - Fax:248-355-3511
Practice Address - Street 1:26400 W 12 MILE RD
Practice Address - Street 2:SUITE 180
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-1700
Practice Address - Country:US
Practice Address - Phone:248-355-5047
Practice Address - Fax:248-355-3511
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-31
Last Update Date:2014-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Multi-Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0M34790Medicare PIN