Provider Demographics
NPI:1184983884
Name:MEDICAL ACNE & SKIN CARE
Entity type:Organization
Organization Name:MEDICAL ACNE & SKIN CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:MATTILA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:906-235-4486
Mailing Address - Street 1:150 W. RIDGE ST.
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855
Mailing Address - Country:US
Mailing Address - Phone:906-235-4486
Mailing Address - Fax:906-680-4077
Practice Address - Street 1:150 W. RIDGE ST.
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855
Practice Address - Country:US
Practice Address - Phone:906-235-4486
Practice Address - Fax:906-680-4077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-15
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301066449207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4117988Medicaid
MI4117988Medicaid