Provider Demographics
NPI:1104090794
Name:BLUE SKIES DERMATOLOGY
Entity type:Organization
Organization Name:BLUE SKIES DERMATOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:COLENE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:CALO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:586-296-1301
Mailing Address - Street 1:29167 JEFFERSON AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081-1331
Mailing Address - Country:US
Mailing Address - Phone:586-296-1301
Mailing Address - Fax:586-296-1304
Practice Address - Street 1:29167 JEFFERSON AVE
Practice Address - Street 2:SUITE B
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48081-1331
Practice Address - Country:US
Practice Address - Phone:586-296-1301
Practice Address - Fax:586-296-1304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-15
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI012868207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIH04371Medicare UPIN