Provider Demographics
NPI:1679085161
Name:WOLVERINE DERMATOLOGY, PC
Entity Type:Organization
Organization Name:WOLVERINE DERMATOLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:FREELAND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-632-0341
Mailing Address - Street 1:1673 GEZON PKWY SW
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519-9519
Mailing Address - Country:US
Mailing Address - Phone:616-243-3376
Mailing Address - Fax:616-243-3377
Practice Address - Street 1:1673 GEZON PKWY SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519-9519
Practice Address - Country:US
Practice Address - Phone:616-243-3376
Practice Address - Fax:616-243-3377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-25
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301084275207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI23D2141314OtherCLIA
MI4301084275OtherSTATE MEDICAL LICENSE