Provider Demographics
NPI:1538192018
Name:ADVANCED DERMATOLOGY PLLC
Entity type:Organization
Organization Name:ADVANCED DERMATOLOGY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:KUTRIATA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:269-429-7546
Mailing Address - Street 1:300 E MAIDEN LN
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-8516
Mailing Address - Country:US
Mailing Address - Phone:269-429-7546
Mailing Address - Fax:269-429-0807
Practice Address - Street 1:300 E MAIDEN LN
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-8516
Practice Address - Country:US
Practice Address - Phone:269-429-7546
Practice Address - Fax:269-429-0807
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2010-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101012454207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0751100205OtherBLUE CROSS
MICG9582OtherPALMETTO GBA GROUP
MI350460011Medicaid
MI0A10115OtherBCBSM GROUP
MICG9582OtherPALMETTO GBA GROUP
MI=========OtherEIN
0N90840Medicare PIN