Provider Demographics
NPI:1518534932
Name:ACADEMIC ALLIANCE IN DERMATOLOGY, INC
Entity Type:Organization
Organization Name:ACADEMIC ALLIANCE IN DERMATOLOGY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:RUTH
Authorized Official - Last Name:PETERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-766-0111
Mailing Address - Street 1:5210 WEBB RD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33615-4518
Mailing Address - Country:US
Mailing Address - Phone:813-882-9986
Mailing Address - Fax:813-882-9849
Practice Address - Street 1:2044 TRINITY OAKS BLVD STE 130
Practice Address - Street 2:
Practice Address - City:TRINITY
Practice Address - State:FL
Practice Address - Zip Code:34655-4405
Practice Address - Country:US
Practice Address - Phone:727-375-5961
Practice Address - Fax:727-376-8710
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ACADEMIC ALLIANCE IN DERMATOLOGY, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-06-04
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Single Specialty
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric DermatologyGroup - Single Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL270808624Medicaid