Provider Demographics
NPI:1306082755
Name:BAY AREA DERMATOLOGY
Entity type:Organization
Organization Name:BAY AREA DERMATOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:J
Authorized Official - Last Name:SIMONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-941-4114
Mailing Address - Street 1:999 SIXTH ST
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-2301
Mailing Address - Country:US
Mailing Address - Phone:231-941-4114
Mailing Address - Fax:231-941-0878
Practice Address - Street 1:999 SIXTH ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2301
Practice Address - Country:US
Practice Address - Phone:231-941-4114
Practice Address - Fax:231-941-0878
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-06
Last Update Date:2009-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301039948174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2114154Medicaid