Provider Demographics
NPI:1780861781
Name:JACKSONVILLE SKIN CANCER CENTER, P.A.
Entity Type:Organization
Organization Name:JACKSONVILLE SKIN CANCER CENTER, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:LUTZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-737-0111
Mailing Address - Street 1:4465 BAYMEADOWS RD STE 5
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32217-4727
Mailing Address - Country:US
Mailing Address - Phone:904-737-0111
Mailing Address - Fax:904-737-4422
Practice Address - Street 1:4465 BAYMEADOWS RD STE 5
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32217-4727
Practice Address - Country:US
Practice Address - Phone:904-737-0111
Practice Address - Fax:904-737-4422
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-22
Last Update Date:2012-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Single Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL42484OtherBLUE CROSS BLUE SHIELD
FL42484OtherBLUE CROSS BLUE SHIELD
FLDB9233Medicare PIN