Provider Demographics
NPI:1396745055
Name:PSORIASIS AND ECZEMA TREATMENT CENTER OF WESTERN MICHIGAN PLLC
Entity type:Organization
Organization Name:PSORIASIS AND ECZEMA TREATMENT CENTER OF WESTERN MICHIGAN PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:MAREK
Authorized Official - Middle Name:A
Authorized Official - Last Name:STAWISKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:616-459-8209
Mailing Address - Street 1:833 MICHIGAN ST NE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-3523
Mailing Address - Country:US
Mailing Address - Phone:616-459-8209
Mailing Address - Fax:616-459-0313
Practice Address - Street 1:833 MICHIGAN ST NE
Practice Address - Street 2:SUITE 102
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-3523
Practice Address - Country:US
Practice Address - Phone:616-459-8209
Practice Address - Fax:616-459-0313
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-26
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty