Healthcare Provider Details

I. General information

NPI: 1285656777
Provider Name (Legal Business Name): NORTHWEST DERMATOLGY GROUP, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 07/27/2018
Certification Date:
Deactivation Date: 02/11/2018
Reactivation Date: 06/05/2018

III. Provider practice location address

29355 NORTHWESTERN HWY #200
SOUTHFIELD MI
48034
US

IV. Provider business mailing address

29355 NORTHWESTERN HWY #200
SOUTHFIELD MI
48034-1053
US

V. Phone/Fax

Practice location:
  • Phone: 248-353-0880
  • Fax:
Mailing address:
  • Phone: 248-353-0880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: EMILY B LEVIN
Title or Position: PRESIDENT
Credential: MD
Phone: 248-353-0880