MEDICARE: DR. KAY ELIZABETH WATNICK MD

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	207N00000X	Dermatology Physician	KW403896	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	KW403896	OTHER	MI	STATE LICENSE

General Provider Information

NPI Number	:	1639123680
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KAY ELIZABETH WATNICK MD

Provider Business Mailing Address
First Line	:	5839 W MAPLE RD STE 109
Second Line	:
City	:	WEST BLOOMFIELD
State	:	MI
Zip	:	48322-2278
Country	:	US
Telephone Number	:	248-855-7500
Fax Number	:	248-855-5627

Provider Business Practice Location Address
First Line	:	5839 W MAPLE RD STE 109
Second Line	:
City	:	WEST BLOOMFIELD
State	:	MI
Zip	:	48322-2278
Country	:	US
Telephone Number	:	248-855-7500
Fax Number	:	248-855-5627

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/22/2006
Last Update Date	:	04/29/2021

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