=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710922661
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BAY VIEW DERMATOLOGY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/17/2006
-----------------------------------------------------
Last Update Date | 08/02/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 560 W MITCHELL ST SUITE 510
-----------------------------------------------------
City | PETOSKEY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49770-2275
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-487-6700
-----------------------------------------------------
Fax | 231-487-0303
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 560 W MITCHELL ST SUITE 510
-----------------------------------------------------
City | PETOSKEY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49770-2275
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-487-6700
-----------------------------------------------------
Fax | 231-487-0303
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. SHERRI S. VAZALES
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 231-487-6700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------