Provider Demographics
NPI:1841252855
Name:SAGINAW VALLEY DERMATOLOGY PC
Entity type:Organization
Organization Name:SAGINAW VALLEY DERMATOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:BRIAN
Authorized Official - Last Name:O'DONNELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:989-793-6505
Mailing Address - Street 1:4705 TOWNE CENTRE RD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48604-2818
Mailing Address - Country:US
Mailing Address - Phone:989-793-6505
Mailing Address - Fax:989-793-7411
Practice Address - Street 1:4705 TOWNE CENTRE RD
Practice Address - Street 2:SUITE 301
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48604-2818
Practice Address - Country:US
Practice Address - Phone:989-793-6505
Practice Address - Fax:989-793-7411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-05
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIDO049303207ND0101X, 207NI0002X, 207ND0900X, 207NS0135X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
No207NI0002XAllopathic & Osteopathic PhysiciansDermatologyClinical & Laboratory Dermatological ImmunologyGroup - Single Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Single Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI070006809OtherRAILROAD MEDICARE
MI0707324351OtherBLUE CROSS BLUE SHIELD
MI103082897Medicaid
MIF07623Medicare UPIN
MI0707324351OtherBLUE CROSS BLUE SHIELD