Derm Institute of West Michigan PLC
Organization Active NPI Dermatology Physician · Caledonia, MI
NPI 1003460874 · NPPES record last updated Jul 27, 2023
Key facts
- NPI
- 1003460874
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Dermatology Physician 207N00000X
- Legal business name
- DERM INSTITUTE OF WEST MICHIGAN PLC
- Practice address
- 1661 Crystal Springs Blvd SE
Caledonia, MI 49316-4931 - Phone
- (616) 326-0114
- Fax
- (616) 369-3790
- NPI assigned
- Jul 30, 2019
- Organization subpart
- No
Authorized official
- Name
- Dr. Kristi Beth Hawley, DO
- Title
- Sole MBR
- Phone
- (740) 606-7403
Practitioners 12
-
Kristi B Hawley, D.O
-
Nicole M. Bossenbroek, M.D.
-
Kelly Ann Murphy, DNP, FNP-C
-
Douglas Mark Richley, D.O.
-
Bryan Gray, DO
-
Lela Lankerani, D.O.
-
Lisa Kaye Bowersox, PA-C
-
Alexis Nichole Batiste, APRN AGNP-C
-
Thingal G Masar, FNP-C
-
Lauren M Rubino, ARNP
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 23D2185277 | Derm Institute of West Michigan, PLC the | Compliance | May 9, 2027 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in MI
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20190910003225 | MI | Part B Supplier - Clinic/Group Practice | 5092044487 |
Receives reassigned benefits from 9 practitioners Practice locations: Caledonia, MI; Petoskey, MI |
National Provider Directory
Locations
1661 Crystal Springs Blvd SE
Caledonia, MI 49316
Phone (616) 326-0114
6750 Kalamazoo Ave SE
Ste C
Grand Rapids, MI 49508
Phone (616) 656-0505
6750 Kalamazoo Ave SE
Ste Cd
Grand Rapids, MI 49508
311 W Mitchell St
Petoskey, MI 49770
Phone (231) 224-6361
Interoperability endpoints
- https://app.meldrx.com/api/fhir/ez_00097
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dermatology Physician |
207N00000X | Yes |
Addresses
Primary practice location
1661 Crystal Springs Blvd SE
Caledonia, MI 49316-4931
Mailing address
7234 Tory Dr
Hudsonville, MI 49426-9066
Phone (616) 485-2012
Other names
- DERM INSTITUTE
Other providers in Caledonia, MI
- Daniel & Max, LLC
- Elissa Jo Davenport
- Luke Delong
- Paula Delorm
- Carlie Demeester
- Brittany Lynn Deur
- Carrie Dewolfe
- Alexis Nicole Dickerson
- Amanda Dill
- Mallory Dines
All providers in Caledonia, MI · Dermatology Physician in Michigan
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jul 27, 2023. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.