Healthcare Provider Details

I. General information

NPI: 1831110774
Provider Name (Legal Business Name): DRS IACOBELLI & DIGREGORIO, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2006
Last Update Date: 08/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16510 19 MILE RD
CLINTON TWP MI
48038-1106
US

IV. Provider business mailing address

16510 19 MILE RD
CLINTON TWP MI
48038-1106
US

V. Phone/Fax

Practice location:
  • Phone: 586-263-7200
  • Fax: 586-263-5331
Mailing address:
  • Phone: 586-263-7200
  • Fax: 586-263-5331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: THERESA M KNOBLOCK
Title or Position: OFFICE MANAGER
Credential:
Phone: 586-263-7200