Provider Demographics
NPI:1902672652
Name:BASE DERMATOLOGY, PC
Entity Type:Organization
Organization Name:BASE DERMATOLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SOFEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-563-2489
Mailing Address - Street 1:25504 SHERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48070-1752
Mailing Address - Country:US
Mailing Address - Phone:248-563-2489
Mailing Address - Fax:
Practice Address - Street 1:26400 W 12 MILE RD STE 180
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-1785
Practice Address - Country:US
Practice Address - Phone:248-355-5047
Practice Address - Fax:248-355-3511
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-04
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1043452139OtherPERSONAL NPI