Provider Demographics
NPI:1992035695
Name:MACINNIS DERMATOLOGY
Entity Type:Organization
Organization Name:MACINNIS DERMATOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MACINNIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-350-5230
Mailing Address - Street 1:PO BOX 490558
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34749-0558
Mailing Address - Country:US
Mailing Address - Phone:352-350-5230
Mailing Address - Fax:
Practice Address - Street 1:27950 US HIGHWAY 27
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-9050
Practice Address - Country:US
Practice Address - Phone:352-350-5230
Practice Address - Fax:866-539-7193
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-04
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME100399207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLH49980Medicare UPIN