Provider Demographics
NPI:1467568477
Name:SOUTH TAMPA DERMATOLOGY PL
Entity Type:Organization
Organization Name:SOUTH TAMPA DERMATOLOGY PL
Other - Org Name:SOUTH TAMPA DERMATOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:G
Authorized Official - Last Name:FLYNN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-872-9551
Mailing Address - Street 1:2605 W SWANN AVE
Mailing Address - Street 2:SUITE #300
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33609-4039
Mailing Address - Country:US
Mailing Address - Phone:813-872-9551
Mailing Address - Fax:813-872-9554
Practice Address - Street 1:2605 W SWANN AVE
Practice Address - Street 2:SUITE #300
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-4039
Practice Address - Country:US
Practice Address - Phone:813-872-9551
Practice Address - Fax:813-872-9554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME66332174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL26291AOtherBCBS
FL26291AOtherBCBS
FLK6565Medicare ID - Type Unspecified