Provider Demographics
NPI:1861430779
Name:ASSOCIATES IN DERMATOLOGY OF TRAVERSE CITY PC
Entity type:Organization
Organization Name:ASSOCIATES IN DERMATOLOGY OF TRAVERSE CITY PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOAN
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:GRINER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:231-935-0625
Mailing Address - Street 1:3643 W FRONT ST
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-7760
Mailing Address - Country:US
Mailing Address - Phone:231-935-0625
Mailing Address - Fax:231-935-0626
Practice Address - Street 1:3643 W FRONT ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-7759
Practice Address - Country:US
Practice Address - Phone:231-935-0625
Practice Address - Fax:231-935-0626
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJG058054207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIDF3512OtherRAILROAD MEDICARE
MIF85530Medicare UPIN
MIOM97620Medicare PIN
MIH53601Medicare UPIN