Provider Demographics
NPI:1215102330
Name:KAY WATNICK MD PC
Entity type:Organization
Organization Name:KAY WATNICK MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:KAY
Authorized Official - Middle Name:
Authorized Official - Last Name:WATNICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-855-7500
Mailing Address - Street 1:6900 ORCHARD LAKE ROAD
Mailing Address - Street 2:STE 209
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-3405
Mailing Address - Country:US
Mailing Address - Phone:248-855-7500
Mailing Address - Fax:248-855-5627
Practice Address - Street 1:6900 ORCHARD LAKE RD
Practice Address - Street 2:STE 209
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-3405
Practice Address - Country:US
Practice Address - Phone:248-855-7500
Practice Address - Fax:248-855-5627
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-29
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301403896207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIB48747Medicare UPIN