MEDICARE: WEST BLOOMFIELD DERMATOLOGY AND MOHS SURGERY

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

General Provider Information

NPI Number	:	1841897238
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WEST BLOOMFIELD DERMATOLOGY AND MOHS SURGERY

Provider Business Mailing Address
First Line	:	5839 MAPLE RD
Second Line	:	SUITE 109
City	:	WEST BLOOMFIELD
State	:	MI
Zip	:	48322
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	:

Authorized Official
Title or Position	:	PRACTICE MANAGER
Name	:	LINDA PETERLIN
Credential	:
Telephone Number	:	248-855-7500

Provider Enumeration Date	:	10/08/2020
Last Update Date	:	03/17/2026

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