Provider Demographics
NPI:1801082987
Name:NORTHERN MICHIGAN DERMATOLOGY PC
Entity type:Organization
Organization Name:NORTHERN MICHIGAN DERMATOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/CORPORATE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:ROGER
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:231-627-3800
Mailing Address - Street 1:125 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CHEBOYGAN
Mailing Address - State:MI
Mailing Address - Zip Code:49721-1637
Mailing Address - Country:US
Mailing Address - Phone:231-627-3800
Mailing Address - Fax:231-627-2482
Practice Address - Street 1:125 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CHEBOYGAN
Practice Address - State:MI
Practice Address - Zip Code:49721-1637
Practice Address - Country:US
Practice Address - Phone:231-627-3800
Practice Address - Fax:231-627-2482
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-21
Last Update Date:2010-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIWG008271207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0751600054OtherBCBSM
MI3055165Medicaid
0751600054OtherBCBSM