Provider Demographics
NPI:1649542689
Name:MICHIGAN DERMATOLOGY CENTER, PLLC
Entity type:Organization
Organization Name:MICHIGAN DERMATOLOGY CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:FARAH
Authorized Official - Middle Name:KATHERINE
Authorized Official - Last Name:MALICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-743-9330
Mailing Address - Street 1:38865 DEQUINDRE RD
Mailing Address - Street 2:SUITE #104
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-6812
Mailing Address - Country:US
Mailing Address - Phone:248-743-9330
Mailing Address - Fax:248-743-9332
Practice Address - Street 1:38865 DEQUINDRE RD
Practice Address - Street 2:SUITE #104
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48083-6812
Practice Address - Country:US
Practice Address - Phone:248-743-9330
Practice Address - Fax:248-743-9332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-07
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301083995207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty