=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689413445
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIGHTHOUSE DERMATOLOGY AND SKIN CANCER SPECIALISTS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2024
-----------------------------------------------------
Last Update Date | 04/18/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 26901 HARPER AVE
-----------------------------------------------------
City | SAINT CLAIR SHORES
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48081-1971
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-726-7646
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6363 29 MILE RD
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48095-2401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-381-8775
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | RACHEL ESCOBAR
-----------------------------------------------------
Credential | NP
-----------------------------------------------------
Telephone | 248-726-7646
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207ND0101X
-----------------------------------------------------
Taxonomy Name | MOHS-Micrographic Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------