Basic Information
| Provider Information | |||||||||
| NPI: | 1811069222 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DERMATOLOGY ASSOCIATES OF NORTHERN MICHIGAN, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4170 CEDAR BLUFF DRIVE | ||||||||
| Address2: | |||||||||
| City: | PETOSKEY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2314872230 | ||||||||
| FaxNumber: | 2314876172 | ||||||||
| Practice Location | |||||||||
| Address1: | 4170 CEDAR BLUFF DRIVE | ||||||||
| Address2: | |||||||||
| City: | PETOSKEY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2314872230 | ||||||||
| FaxNumber: | 2314876172 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | COTTER | ||||||||
| AuthorizedOfficialFirstName: | MURRAY | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2314872230 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | II | ||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 070B410100 | 01 | MI | BCBS GROUP | OTHER | OM75570 | 01 | MI | MEDICARE GROUP | OTHER |