Provider Demographics
NPI:1700429685
Name:GREATER MICHIGAN DERMATOLOGY, PLLC
Entity Type:Organization
Organization Name:GREATER MICHIGAN DERMATOLOGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KELSEY
Authorized Official - Middle Name:
Authorized Official - Last Name:LAWRENCE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:810-498-4354
Mailing Address - Street 1:849 HEALTH PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-7383
Mailing Address - Country:US
Mailing Address - Phone:415-802-1310
Mailing Address - Fax:810-498-4355
Practice Address - Street 1:849 HEALTH PARK BLVD
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-7383
Practice Address - Country:US
Practice Address - Phone:810-498-4354
Practice Address - Fax:810-498-4355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-23
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1225410756OtherNPI