Provider Demographics
NPI:1609536267
Name:SANDERS MEDICAL GROUP, PLLC
Entity Type:Organization
Organization Name:SANDERS MEDICAL GROUP, PLLC
Other - Org Name:SACRED HEART DERMATOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FOUNDER & MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BLAKE
Authorized Official - Middle Name:
Authorized Official - Last Name:SANDERS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:980-550-2400
Mailing Address - Street 1:170 MEDICAL PARK RD STE 203
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-8540
Mailing Address - Country:US
Mailing Address - Phone:980-550-2400
Mailing Address - Fax:950-550-2424
Practice Address - Street 1:170 MEDICAL PARK RD STE 203
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-8540
Practice Address - Country:US
Practice Address - Phone:980-550-2400
Practice Address - Fax:950-550-2424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-23
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty