Provider Demographics
NPI:1942370507
Name:KOGER DERMATOLOGY P.C.
Entity Type:Organization
Organization Name:KOGER DERMATOLOGY P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:O'NEAL
Authorized Official - Middle Name:WILSON
Authorized Official - Last Name:KOGER
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:248-435-6622
Mailing Address - Street 1:30301 WOODWARD AVE STE 120
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-0981
Mailing Address - Country:US
Mailing Address - Phone:248-435-6622
Mailing Address - Fax:248-435-7453
Practice Address - Street 1:30301 WOODWARD AVE STE 120
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-0981
Practice Address - Country:US
Practice Address - Phone:248-435-6622
Practice Address - Fax:248-435-7453
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301053536207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI070F37332OtherBCBS
MIOM36310Medicare ID - Type Unspecified