Healthcare Provider Details

I. General information

NPI: 1396745055
Provider Name (Legal Business Name): PSORIASIS AND ECZEMA TREATMENT CENTER OF WESTERN MICHIGAN PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2005
Last Update Date: 03/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

833 MICHIGAN ST NE SUITE 102
GRAND RAPIDS MI
49503-3523
US

IV. Provider business mailing address

833 MICHIGAN ST NE SUITE 102
GRAND RAPIDS MI
49503-3523
US

V. Phone/Fax

Practice location:
  • Phone: 616-459-8209
  • Fax: 616-459-0313
Mailing address:
  • Phone: 616-459-8209
  • Fax: 616-459-0313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. MAREK A STAWISKI
Title or Position: PHYSICIAN
Credential: MD
Phone: 616-459-8209