MEDICARE: DERMATOLOGY CENTER OF OXFORD, P.C.

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	5101010573	MI

General Provider Information

NPI Number	:	1518146323
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DERMATOLOGY CENTER OF OXFORD, P.C.

Provider Business Mailing Address
First Line	:	2227 ROCK VALLEY RD
Second Line	:	SUITE A
City	:	METAMORA
State	:	MI
Zip	:	48455-9333
Country	:	US
Telephone Number	:	248-390-0435
Fax Number	:

Provider Business Practice Location Address
First Line	:	2227 ROCK VALLEY RD
Second Line	:	SUITE A
City	:	METAMORA
State	:	MI
Zip	:	48455-9333
Country	:	US
Telephone Number	:	248-390-0435
Fax Number	:

Authorized Official
Title or Position	:	PHYSICIAN/PRESIDENT
Name	:	DR. THOMAS HENRY BONINO JR.
Credential	:	D.O.
Telephone Number	:	248-390-0435

Provider Enumeration Date	:	10/29/2007
Last Update Date	:	10/29/2007

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