Provider Demographics
NPI:1891169736
Name:DYNAMIC DERMATOLOGY AND SKIN CANCER CENTER PC
Entity Type:Organization
Organization Name:DYNAMIC DERMATOLOGY AND SKIN CANCER CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MURRAY
Authorized Official - Middle Name:ADRIAN
Authorized Official - Last Name:COTTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:989-356-3485
Mailing Address - Street 1:1087 MAPLE WAY
Mailing Address - Street 2:
Mailing Address - City:HARBOR SPRINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49740-9234
Mailing Address - Country:US
Mailing Address - Phone:989-356-3485
Mailing Address - Fax:989-356-6396
Practice Address - Street 1:105 ARBOR LN
Practice Address - Street 2:
Practice Address - City:ALPENA
Practice Address - State:MI
Practice Address - Zip Code:49707-1301
Practice Address - Country:US
Practice Address - Phone:989-356-3485
Practice Address - Fax:989-356-6396
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-16
Last Update Date:2015-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMC081921207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI207N00000XOtherTAXONOMY
MIMC081921OtherSTATE LICENCE
MI207N00000XOtherTAXONOMY