MEDICARE: MICHIGAN CENTER FOR DERMATOLOGY PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM2500X	Medical Specialty Clinic/Center	4301043778	MI

General Provider Information

NPI Number	:	1053527226
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MICHIGAN CENTER FOR DERMATOLOGY PLLC

Provider Business Mailing Address
First Line	:	835 MASON ST STE C200
Second Line	:
City	:	DEARBORN
State	:	MI
Zip	:	48124-2231
Country	:	US
Telephone Number	:	313-274-5810
Fax Number	:	313-274-1499

Provider Business Practice Location Address
First Line	:	835 MASON ST STE C200
Second Line	:
City	:	DEARBORN
State	:	MI
Zip	:	48124-2231
Country	:	US
Telephone Number	:	313-274-5810
Fax Number	:	313-274-1499

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	MR. THOMAS P. WALDINGER
Credential	:	M.D.
Telephone Number	:	313-274-5810

Provider Enumeration Date	:	05/15/2007
Last Update Date	:	03/17/2018

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