Healthcare Provider Details

I. General information

NPI: 1073607925
Provider Name (Legal Business Name): KALAMAZOO DERMATOLOGY, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 01/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6100 NEWPORT RD STE 100
PORTAGE MI
49002-9235
US

IV. Provider business mailing address

6100 NEWPORT RD STE 100
PORTAGE MI
49002-9235
US

V. Phone/Fax

Practice location:
  • Phone: 269-343-4679
  • Fax: 269-343-5929
Mailing address:
  • Phone: 269-343-4679
  • Fax: 269-343-5929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: LORI KOLLIN
Title or Position: PRACTICE MANAGER
Credential:
Phone: 269-343-4679