=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538192018
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANCED DERMATOLOGY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/08/2006
-----------------------------------------------------
Last Update Date | 03/25/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 300 E MAIDEN LN
-----------------------------------------------------
City | SAINT JOSEPH
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49085-8516
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-429-7546
-----------------------------------------------------
Fax | 269-429-0807
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 300 E MAIDEN LN
-----------------------------------------------------
City | SAINT JOSEPH
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49085-8516
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-429-7546
-----------------------------------------------------
Fax | 269-429-0807
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PROVIDER
-----------------------------------------------------
Name | MARK A KUTRIATA
-----------------------------------------------------
Credential | D.O.
-----------------------------------------------------
Telephone | 269-429-7546
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number | 5101012454
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------