Healthcare Provider Details

I. General information

NPI: 1780933432
Provider Name (Legal Business Name): DERMATOLOGY AT MIDTOWNE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2012
Last Update Date: 03/18/2024
Certification Date: 03/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 MIDTOWNE ST NE SUITE 301
GRAND RAPIDS MI
49503-5729
US

IV. Provider business mailing address

555 MIDTOWNE ST NE STE 301
GRAND RAPIDS MI
49503-5729
US

V. Phone/Fax

Practice location:
  • Phone: 616-248-8864
  • Fax: 616-248-8874
Mailing address:
  • Phone: 616-248-8864
  • Fax: 616-248-8874

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. DIPA SUMAN PATEL
Title or Position: PHYSICIAN/OWNER
Credential: MD
Phone: 616-248-8864