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General NPI Number Information
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NPI Number | 1164874616
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Entity Type | Organization
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Legal Business Name | CLEAR THE DERMATOLOGY CLINIC PC
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Dates
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Enumeration Date | 07/08/2016
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Last Update Date | 08/02/2016
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Provider Practice Location Address
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Address Line | 116 W MITCHELL ST
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City | PETOSKEY
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State | MI
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Zip | 49770-2357
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Country | US
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Telephone | 231-348-0766
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Fax |
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Provider Business Mailing Address
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Address Line | 116 W MITCHELL ST
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City | PETOSKEY
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State | MI
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Zip | 49770-2357
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Country | US
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Telephone | 231-348-0766
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Fax |
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Authorized Official
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Title or Position | BILLING COORDINATOR
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Name | CHRISTY RACIGNOL
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Credential |
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Telephone | 231-348-2828
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | 4301053221
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 5601004147
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License Number State | MI
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