Basic Information
| Provider Information | |||||||||
| NPI: | 1427141332 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FLORIDA SKIN CANCER & DERMATOLOGY SPECIALISTS, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 357730 | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326357730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523717546 | ||||||||
| FaxNumber: | 3523357546 | ||||||||
| Practice Location | |||||||||
| Address1: | 3700 NW 83RD ST | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326065603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523717546 | ||||||||
| FaxNumber: | 3523357546 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2006 | ||||||||
| LastUpdateDate: | 10/22/2007 | ||||||||
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| AuthorizedOfficialLastName: | SKIDMORE | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3523717546 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | ME59336 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | DC1427 | 01 | FL | RAILROAD MEDICARE GROUP # | OTHER | P00057075 | 01 | FL | RAILROAD MEDICARE PIN | OTHER |