Organization
NORTHWESTERN MICHIGAN DERMATOLOGY
Active
Organization subpart
No
Provider details
NPI number
Authorized official
SOUMIT SHAM PENDHARKAR MHA (OFFICE MANAGER)
(231) 935-8717
Entity
Organization
Contact information
Practice address
550 MUNSON AVE, SUITE 200, TRAVERSE CITY, MI 49686-3580
(231) 935-8717
(231) 935-9230
Mailing address
550 MUNSON AVE, SUITE 200, TRAVERSE CITY, MI 49686-3580
(231) 935-8717
(231) 935-9230
Taxonomy
Speciality
Code
Description
License number
State
207ND0101X
MOHS-Micrographic Surgery Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1285743393
NPI
MI
01
—
1437268661
NPI
MI
01
—
1770692873
NPI NUMBER
MI
01
—
1962511097
NPI
MI
05
—
1997138
—
MI
05
—
3347473
—
MI
01
—
4301063462
MI LICENSE
MI
01
—
4301067697
MI LICENSE
MI
01
—
4301077553
MI LICENSE
MI
01
—
4301406284
MICHIGAN LICENSE
MI
05
—
4317989
—
MI
Enumeration date
05/17/2007
Last updated
08/22/2020
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