MEDICARE: JOAN M GRINER LICHT MD

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	207NS0135X	Procedural Dermatology Physician	JG058054	MI

General Provider Information

NPI Number	:	1710902945
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOAN M GRINER LICHT MD

Provider Business Mailing Address
First Line	:	3643 W FRONT ST
Second Line	:	SUITE A
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49684-7759
Country	:	US
Telephone Number	:	231-935-0620
Fax Number	:	231-935-0626

Provider Business Practice Location Address
First Line	:	3643 W FRONT ST STE A
Second Line	:
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49684-7760
Country	:	US
Telephone Number	:	231-935-0620
Fax Number	:	231-935-0626

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/12/2006
Last Update Date	:	10/21/2014

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