NPIMap

Organization Active NPI

Main Street Dermatology, PLLC

  • Dermatology Physician
  • Clarkston, MI
National Provider Identifier
1881371946
Registry record updated Aug 3, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Dermatology PhysicianTaxonomy code 207N00000X
Legal business name
MAIN STREET DERMATOLOGY, PLLC
Practice address
5885 S Main St Ste 1
Clarkston, MI 48346-2981
Phone
(248) 238-8059
NPI assigned
Jun 30, 2023
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 3, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Kenzie Gardner, NPNPI 1720596802
Title
Nurse Practitioner, Operator
Phone
(614) 507-3765

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Dermatology PhysicianGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 207N00000X Primary

Addresses

Primary practice location

5885 S Main St Ste 1
Clarkston, MI 48346-2981

Mailing address

5885 S Main St Ste 1
Clarkston, MI 48346-2981
Phone (248) 238-8059

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MI

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20230920000987 MI Part B Supplier - Clinic/Group Practice 3476917766 Receives reassigned benefits from 8 practitioners
Practice locations: Clarkston, MI

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 8

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1688083200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1691020800000",
    "number": "1881371946",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5885 S MAIN ST STE 1",
            "city": "CLARKSTON",
            "state": "MI",
            "postal_code": "483462981",
            "telephone_number": "248-238-8059"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5885 S MAIN ST STE 1",
            "city": "CLARKSTON",
            "state": "MI",
            "postal_code": "483462981",
            "telephone_number": "248-238-8059"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MAIN STREET DERMATOLOGY, PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2023-06-30",
        "last_updated": "2023-08-03",
        "certification_date": "2023-08-03",
        "status": "A",
        "authorized_official_last_name": "GARDNER",
        "authorized_official_first_name": "KENZIE",
        "authorized_official_title_or_position": "NURSE PRACTITIONER, OPERATOR",
        "authorized_official_telephone_number": "614-507-3765",
        "authorized_official_credential": "NP"
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Dermatology",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Clarkston, MI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 3, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.