MEDICARE: LIGHTHOUSE DERMATOLOGY AND SKIN CANCER SPECIALISTS

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
2	207ND0101X	MOHS-Micrographic Surgery Physician

General Provider Information

NPI Number	:	1689413445
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIGHTHOUSE DERMATOLOGY AND SKIN CANCER SPECIALISTS

Provider Business Mailing Address
First Line	:	6363 29 MILE RD
Second Line	:
City	:	WASHINGTON
State	:	MI
Zip	:	48095-2401
Country	:	US
Telephone Number	:	586-381-8775
Fax Number	:

Provider Business Practice Location Address
First Line	:	26901 HARPER AVE
Second Line	:
City	:	SAINT CLAIR SHORES
State	:	MI
Zip	:	48081-1971
Country	:	US
Telephone Number	:	248-726-7646
Fax Number	:

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	RACHEL ESCOBAR
Credential	:	NP
Telephone Number	:	248-726-7646

Provider Enumeration Date	:	05/22/2024
Last Update Date	:	04/18/2025

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