Healthcare Provider Details

I. General information

NPI: 1811041890
Provider Name (Legal Business Name): LENISE A. BANSE, M.D.,P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 06/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42452 HAYES RD SUITE 3
CLINTON TOWNSHIP MI
48038-6771
US

IV. Provider business mailing address

42452 HAYES RD SUITE 3
CLINTON TOWNSHIP MI
48038-6771
US

V. Phone/Fax

Practice location:
  • Phone: 586-263-3130
  • Fax: 586-263-5183
Mailing address:
  • Phone: 586-263-3130
  • Fax: 586-263-5183

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number4301047653
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License Number4301047653
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number4301047653
License Number StateMI

VIII. Authorized Official

Name: DR. LENISE BANSE
Title or Position: OWNER
Credential: M.D.
Phone: 586-263-3130