Provider Demographics
NPI:1093061582
Name:FLORIDA DERMATOLOGY AND SKIN CANCER SPECIALISTS PL
Entity Type:Organization
Organization Name:FLORIDA DERMATOLOGY AND SKIN CANCER SPECIALISTS PL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:SCANNON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-877-4811
Mailing Address - Street 1:4200 N ARMENIA AVE
Mailing Address - Street 2:STE 1
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-6438
Mailing Address - Country:US
Mailing Address - Phone:813-922-3704
Mailing Address - Fax:813-872-8978
Practice Address - Street 1:4200 N ARMENIA AVE
Practice Address - Street 2:STE 1
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6438
Practice Address - Country:US
Practice Address - Phone:813-877-4811
Practice Address - Fax:813-872-8978
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-02
Last Update Date:2014-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Single Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
10D1075937OtherCLIA
DT3661OtherRAILROAD MEDICARE
FLGT410A/BMedicare PIN