Provider Demographics
NPI:1811005341
Name:MID-FLORIDA SKIN CANCER CLINIC
Entity Type:Organization
Organization Name:MID-FLORIDA SKIN CANCER CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:B
Authorized Official - Last Name:COVERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-788-8900
Mailing Address - Street 1:220 N WESTMONTE DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32714
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:220 N WESTMONTE DR
Practice Address - Street 2:SUITE A
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32714
Practice Address - Country:US
Practice Address - Phone:407-788-8900
Practice Address - Fax:407-788-8834
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME34331207N00000X, 207ND0101X, 207NI0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
No207NI0002XAllopathic & Osteopathic PhysiciansDermatologyClinical & Laboratory Dermatological ImmunologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
47314Medicare ID - Type Unspecified
D55007Medicare UPIN