MEDICARE: DERMATOLOGY MEDICAL CENTER OF MI, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician

General Provider Information

NPI Number	:	1477128189
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DERMATOLOGY MEDICAL CENTER OF MI, PC

Provider Business Mailing Address
First Line	:	2545 W SILVER LAKE RD STE 2
Second Line	:
City	:	FENTON
State	:	MI
Zip	:	48430-2662
Country	:	US
Telephone Number	:	810-243-0707
Fax Number	:	810-208-0311

Provider Business Practice Location Address
First Line	:	2545 W SILVER LAKE RD STE 2
Second Line	:
City	:	FENTON
State	:	MI
Zip	:	48430-2662
Country	:	US
Telephone Number	:	810-215-0999
Fax Number	:	810-629-2377

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. NEDIL N/A ALDARONDO-ANTONINI
Credential	:	MD
Telephone Number	:	956-286-3604

Provider Enumeration Date	:	05/25/2021
Last Update Date	:	05/13/2024

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