Provider Demographics
NPI:1164740809
Name:DERMATOLOGY ASSOCIATES, PA
Entity Type:Organization
Organization Name:DERMATOLOGY ASSOCIATES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:SIRAGUSA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-522-5000
Mailing Address - Street 1:1900 HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-4542
Mailing Address - Country:US
Mailing Address - Phone:850-769-7546
Mailing Address - Fax:
Practice Address - Street 1:877 3RD STREET
Practice Address - Street 2:SUITE 3
Practice Address - City:CHIPLEY
Practice Address - State:FL
Practice Address - Zip Code:32428-1855
Practice Address - Country:US
Practice Address - Phone:850-769-7546
Practice Address - Fax:850-215-7771
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-05
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME23244Medicare UPIN