Provider Demographics
NPI:1629169578
Name:FERRARA DERMATOLOGY CLINIC PC
Entity Type:Organization
Organization Name:FERRARA DERMATOLOGY CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:FERRARA JR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-884-5100
Mailing Address - Street 1:20045 MACK AVE
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48236-2322
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20045 MACK AVE
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE WOODS
Practice Address - State:MI
Practice Address - Zip Code:48236-2322
Practice Address - Country:US
Practice Address - Phone:313-884-5100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301057129174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2774745Medicaid
MI0P20070Medicare ID - Type Unspecified
MI2774745Medicaid