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General NPI Number Information
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NPI Number | 1801082987
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Entity Type | Organization
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Legal Business Name | NORTHERN MICHIGAN DERMATOLOGY PC
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Dates
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Enumeration Date | 09/21/2007
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Last Update Date | 10/05/2010
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Provider Practice Location Address
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Address Line | 125 N MAIN ST
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City | CHEBOYGAN
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State | MI
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Zip | 49721-1637
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Country | US
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Telephone | 231-627-3800
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Fax | 231-627-2482
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Provider Business Mailing Address
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Address Line | 125 N MAIN ST
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City | CHEBOYGAN
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State | MI
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Zip | 49721-1637
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Country | US
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Telephone | 231-627-3800
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Fax | 231-627-2482
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Authorized Official
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Title or Position | PHYSICIAN/CORPORATE PRESIDENT
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Name | WILLIAM ROGER GRAY
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Credential | D.O.
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Telephone | 231-627-3800
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | WG008271
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License Number State | MI
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