Provider Demographics
NPI:1174851158
Name:SIDNEY POSSICK M.D.,P.A.
Entity Type:Organization
Organization Name:SIDNEY POSSICK M.D.,P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SIDNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:POSSICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-252-5578
Mailing Address - Street 1:655 N CLYDE MORRIS BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-2321
Mailing Address - Country:US
Mailing Address - Phone:386-252-5578
Mailing Address - Fax:386-257-3660
Practice Address - Street 1:655 N CLYDE MORRIS BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-2321
Practice Address - Country:US
Practice Address - Phone:386-252-5578
Practice Address - Fax:386-257-3660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-02
Last Update Date:2010-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME19498207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCM988AOtherMEDICARE PTAN
FLD57608Medicare UPIN