=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063493096
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRIAN G SANDLER MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/08/2005
-----------------------------------------------------
Last Update Date | 08/28/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 51189 SHELBY PKWY
-----------------------------------------------------
City | SHELBY TWP
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48315-1786
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-997-9700
-----------------------------------------------------
Fax | 586-997-9738
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 51189 SHELBY PKWY
-----------------------------------------------------
City | SHELBY TWP
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48315-1786
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-997-9700
-----------------------------------------------------
Fax | 586-997-9738
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207ND0101X
-----------------------------------------------------
Taxonomy Name | MOHS-Micrographic Surgery Physician
-----------------------------------------------------
License Number | 4301058522
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number | 4301058522
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------