Basic Information
| Provider Information | |||||||||
| NPI: | 1053675660 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DERMATOLOGY ASSOCIATES OF BAY COUNTY, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 HARRISON AVE | ||||||||
| Address2: | |||||||||
| City: | PANAMA CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 324054542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8507691668 | ||||||||
| FaxNumber: | 8507852123 | ||||||||
| Practice Location | |||||||||
| Address1: | 20370 NE BURNS AVE | ||||||||
| Address2: | |||||||||
| City: | BLOUNTSTOWN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 324241045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8507697546 | ||||||||
| FaxNumber: | 8507852123 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2012 | ||||||||
| LastUpdateDate: | 06/28/2012 | ||||||||
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| AuthorizedOfficialLastName: | SIRAGUSA | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | JOHN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT DERMATOLOGY ASSOCIATES | ||||||||
| AuthorizedOfficialTelephone: | 8507691668 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | ME23244 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 000164600 | 05 | FL | MEDICAID |