Healthcare Provider Details

I. General information

NPI: 1114192754
Provider Name (Legal Business Name): ROCHESTER DERMATOLOGY CLINIC, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2008
Last Update Date: 04/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 BARCLAY CIR
ROCHESTER HILLS MI
48307-4573
US

IV. Provider business mailing address

56853 MOUNT VERNON RD
SHELBY TWP MI
48316-4829
US

V. Phone/Fax

Practice location:
  • Phone: 248-843-3131
  • Fax: 248-853-3275
Mailing address:
  • Phone: 248-652-3926
  • Fax: 248-853-3275

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number5101005759
License Number StateMI

VIII. Authorized Official

Name: DR. ROGER CLARENCE BYRD
Title or Position: PRESIDENT
Credential: D.O.
Phone: 248-853-3131