Healthcare Provider Details

I. General information

NPI: 1114489945
Provider Name (Legal Business Name): NOVICE AESTHETICS AND DERMATOLOGY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2019
Last Update Date: 04/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4120 W MAPLE RD STE 206
BLOOMFIELD HILLS MI
48301-3068
US

IV. Provider business mailing address

7456 PADDLE WHEEL CT
BLOOMFIELD HILLS MI
48301-3700
US

V. Phone/Fax

Practice location:
  • Phone: 248-932-3376
  • Fax: 248-932-1046
Mailing address:
  • Phone: 248-932-3376
  • Fax: 248-932-1046

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. FRED MARK NOVICE
Title or Position: OWNER
Credential: MD
Phone: 248-932-3376