Provider Demographics
NPI:1821125584
Name:AMERICAN MOBILE DERMATOLOGY LLC
Entity Type:Organization
Organization Name:AMERICAN MOBILE DERMATOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:JUDE
Authorized Official - Last Name:DEVOURSNEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:561-738-4770
Mailing Address - Street 1:1054 GATEWAY BLVD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33426-8309
Mailing Address - Country:US
Mailing Address - Phone:561-738-4770
Mailing Address - Fax:561-738-9727
Practice Address - Street 1:1054 GATEWAY BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33426-8309
Practice Address - Country:US
Practice Address - Phone:561-738-4770
Practice Address - Fax:561-738-9727
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2013-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME80429174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK4527Medicare ID - Type Unspecified