Provider Demographics
NPI:1104023324
Name:SPENCER DERMATOLOGY & SKIN SURGERY CENTER LLC
Entity Type:Organization
Organization Name:SPENCER DERMATOLOGY & SKIN SURGERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:MONTGOMERY
Authorized Official - Last Name:SPENCER
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MS
Authorized Official - Phone:727-572-1333
Mailing Address - Street 1:900 CARILLON PKWY
Mailing Address - Street 2:SUITE 404
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33716-1115
Mailing Address - Country:US
Mailing Address - Phone:727-572-1333
Mailing Address - Fax:727-572-1331
Practice Address - Street 1:900 CARILLON PKWY
Practice Address - Street 2:SUITE 404
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33716-1115
Practice Address - Country:US
Practice Address - Phone:727-572-1333
Practice Address - Fax:727-572-1331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-29
Last Update Date:2012-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME68471174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1730102385OtherNPI INDIVIDUAL NUMBER
FLK7198Medicare ID - Type UnspecifiedDERMATOLOGIST
FLF27675Medicare UPIN