Provider Demographics
NPI:1841229036
Name:SOUTHEASTERN DERMATOLOGY, PA
Entity Type:Organization
Organization Name:SOUTHEASTERN DERMATOLOGY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:FORD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-422-3376
Mailing Address - Street 1:2040 FLEISCHMANN RD
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-4599
Mailing Address - Country:US
Mailing Address - Phone:850-422-3376
Mailing Address - Fax:850-205-7182
Practice Address - Street 1:2040 FLEISCHMANN RD
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4599
Practice Address - Country:US
Practice Address - Phone:850-422-3376
Practice Address - Fax:850-205-7182
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2016-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000595501Medicaid
FL10D0992605OtherCLIA
FLK2914Medicare PIN