Organization
ADVANCED DERMATOLOGY PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MARK A KUTRIATA D.O. (OWNER/PROVIDER)
(269) 429-7546
Entity
Organization
Contact information
Practice address
300 E MAIDEN LN, SAINT JOSEPH, MI 49085-8516
(269) 429-7546
(269) 429-0807
Mailing address
300 E MAIDEN LN, SAINT JOSEPH, MI 49085-8516
(269) 429-7546
(269) 429-0807
Taxonomy
Speciality
Code
Description
License number
State
207N00000X
Dermatology Physician
Primary
5101012454
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0751100205
BLUE CROSS
—
01
—
0A10115
BCBSM GROUP
MI
05
—
350460011
—
MI
01
—
CG9582
PALMETTO GBA GROUP
MI
Enumeration date
07/08/2006
Last updated
03/25/2010
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