=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942370507
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KOGER DERMATOLOGY P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/09/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 30301 WOODWARD AVE STE 120
-----------------------------------------------------
City | ROYAL OAK
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48073-0981
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-435-6622
-----------------------------------------------------
Fax | 248-435-7453
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 30301 WOODWARD AVE STE 120
-----------------------------------------------------
City | ROYAL OAK
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48073-0981
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-435-6622
-----------------------------------------------------
Fax | 248-435-7453
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. O'NEAL WILSON KOGER JR.
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 248-435-6622
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number | 4301053536
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------