Provider Demographics
NPI:1811041890
Name:LENISE A. BANSE, M.D.,P.C.
Entity Type:Organization
Organization Name:LENISE A. BANSE, M.D.,P.C.
Other - Org Name:NORTHEAST FAMILY DERMATOLOGY CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LENISE
Authorized Official - Middle Name:
Authorized Official - Last Name:BANSE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-263-3130
Mailing Address - Street 1:42452 HAYES RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-6771
Mailing Address - Country:US
Mailing Address - Phone:586-263-3130
Mailing Address - Fax:586-263-5183
Practice Address - Street 1:42452 HAYES RD
Practice Address - Street 2:SUITE 3
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-6771
Practice Address - Country:US
Practice Address - Phone:586-263-3130
Practice Address - Fax:586-263-5183
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2010-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301047653207N00000X, 207NP0225X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric DermatologyGroup - Single Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA101151OtherPREFERRED CHOICES
MA0500688OtherBCBS OF MICHIGAN
MI4037111OtherAETNA
MA131180573496OtherHUMANA
MIDR500262OtherMCARE
MI0705006881OtherBLUE CROSS BLUE SHIELD OF MICHIGAN
MI900013288OtherPRIORITY HEALTH
MI101151OtherCARE CHOICES
MI131180573496OtherHUMANA
MI155665OtherGREAT LAKES HEALTH PLAN
MI0500688001OtherMEDICARE PLUS BLUE
MI2806900Medicaid
MI80862BOtherHEALTH ALLIANCE PLAN
MIMO22874OtherTRICARE
MA131180573496OtherHUMANA
MI900013288OtherPRIORITY HEALTH
MI2806900Medicaid