Active NPI
Northwestern Michigan Dermatology
- MOHS-Micrographic Surgery Physician
- Traverse City, MI
National Provider Identifier
1346457488
On this page
Key facts
NPPES NPI Registry- Primary specialty
- MOHS-Micrographic Surgery Physician
- Legal business name
- NORTHWESTERN MICHIGAN DERMATOLOGY
- Practice address
- 550 Munson Ave
Suite 200
Traverse City, MI 49686-3580 - Phone
- (231) 935-8717
- Fax
- (231) 935-9230
- NPI assigned
- May 17, 2007
- Organization subpart
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Authorized official
- Name
- Soumit Sham Pendharkar, MHA
- Title
- Office Manager
- Phone
- (231) 935-8717
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| MOHS-Micrographic Surgery Physician | 207ND0101X | Primary |
Addresses
Primary practice location
550 Munson Ave
Suite 200
Traverse City, MI 49686-3580
Mailing address
550 Munson Ave
Suite 200
Traverse City, MI 49686-3580
Phone (231) 935-8717
Other identifiers 11
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1962511097 | Other | MI | NPI |
| 1285743393 | Other | MI | NPI |
| 4301063462 | Other | MI | MI LICENSE |
| 4301077553 | Other | MI | MI LICENSE |
| 1437268661 | Other | MI | NPI |
| 4301406284 | Other | MI | MICHIGAN LICENSE |
| 1770692873 | Other | MI | NPI NUMBER |
| 1997138 | Medicaid | MI | |
| 3347473 | Medicaid | MI | |
| 4301067697 | Other | MI | MI LICENSE |
| 4317989 | Medicaid | MI |
National Provider Directory
National Provider DirectoryPractitioners & affiliated clinicians
Practitioners 6
Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.
-
- Dermatology Physician
- Traverse City, MI
- NPI 1285743393
-
- Dermatology Physician
- Traverse City, MI
- NPI 1437268661
-
- Dermatology Physician
- Rockford, MI
- NPI 1356542500
-
- Medical Physician Assistant
- Traverse City, MI
- NPI 1144503491
-
- Physician Assistant
- Traverse City, MI
- NPI 1396479440
-
- Family Medicine Physician
- Mission Hills, CA
- NPI 1407268626
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1179360000000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1598054400000",
"number": "1346457488",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "550 MUNSON AVE",
"address_2": "SUITE 200",
"city": "TRAVERSE CITY",
"state": "MI",
"postal_code": "496863580",
"telephone_number": "231-935-8717",
"fax_number": "231-935-9230"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "550 MUNSON AVE",
"address_2": "SUITE 200",
"city": "TRAVERSE CITY",
"state": "MI",
"postal_code": "496863580",
"telephone_number": "231-935-8717",
"fax_number": "231-935-9230"
}
],
"practiceLocations": [],
"basic": {
"organization_name": "NORTHWESTERN MICHIGAN DERMATOLOGY",
"organizational_subpart": "NO",
"enumeration_date": "2007-05-17",
"last_updated": "2020-08-22",
"status": "A",
"authorized_official_last_name": "PENDHARKAR",
"authorized_official_first_name": "SOUMIT",
"authorized_official_middle_name": "SHAM",
"authorized_official_title_or_position": "OFFICE MANAGER",
"authorized_official_telephone_number": "231-935-8717",
"authorized_official_credential": "MHA"
},
"taxonomies": [
{
"code": "207ND0101X",
"taxonomy_group": "193400000X SINGLE SPECIALTY GROUP",
"desc": "Dermatology, MOHS-Micrographic Surgery",
"state": null,
"license": null,
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "NPI",
"identifier": "1962511097",
"state": "MI"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "NPI",
"identifier": "1285743393",
"state": "MI"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "MI LICENSE",
"identifier": "4301063462",
"state": "MI"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "MI LICENSE",
"identifier": "4301077553",
"state": "MI"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "NPI",
"identifier": "1437268661",
"state": "MI"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "MICHIGAN LICENSE",
"identifier": "4301406284",
"state": "MI"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "NPI NUMBER",
"identifier": "1770692873",
"state": "MI"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "1997138",
"state": "MI"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "3347473",
"state": "MI"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "MI LICENSE",
"identifier": "4301067697",
"state": "MI"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "4317989",
"state": "MI"
}
],
"endpoints": [],
"other_names": []
}Other providers in Traverse City, MI
- Northwest Michigan Heart & Vascular Specialists
- Northwest Michigan Surgery Center LLC
- Northwest Michigan Surgical Group, P.C.
- Northwest Senior Resources Incorporated
- Northwestern Michigan College
- Northwestern Michigan Dermatology PC
- Northwestern Michigan Emergency Physicians PC
- Northwestern Michigan Neonatology
- Northwood Cosmetic Dental Group, PC
- Northwood Obstetrics and Gynecology,PC
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.