Provider Demographics
NPI:1720259435
Name:MARK L. NELSON, MD, PHD, PC
Entity Type:Organization
Organization Name:MARK L. NELSON, MD, PHD, PC
Other - Org Name:AAA AMERICAN DERMATOLOGY ASSOCIATES
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD PHD
Authorized Official - Phone:248-540-9100
Mailing Address - Street 1:60 W BIG BEAVER RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48304-3909
Mailing Address - Country:US
Mailing Address - Phone:248-540-9100
Mailing Address - Fax:248-540-1223
Practice Address - Street 1:60 W BIG BEAVER RD
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48304-3909
Practice Address - Country:US
Practice Address - Phone:248-540-9100
Practice Address - Fax:248-540-1223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-20
Last Update Date:2009-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301045147207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI070002264OtherRAILROAD MEDICARE
MI0706336300OtherBCBS MI
MI0F34680OtherBCBSM TYPE 11
MIB47357Medicare UPIN
MI0706336300OtherBCBS MI
MIMI1875001Medicare PIN
MI0F34680OtherBCBSM TYPE 11