Provider Demographics
NPI:1295903276
Name:ADVANCED DERMATOLOGY, PA
Entity type:Organization
Organization Name:ADVANCED DERMATOLOGY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:NG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-247-4300
Mailing Address - Street 1:1361 13TH AVE S
Mailing Address - Street 2:SUITE 180
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-3233
Mailing Address - Country:US
Mailing Address - Phone:904-247-4300
Mailing Address - Fax:904-247-4350
Practice Address - Street 1:1361 13TH AVE S
Practice Address - Street 2:SUITE 180
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-3233
Practice Address - Country:US
Practice Address - Phone:904-247-4300
Practice Address - Fax:904-247-4350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-13
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME63182207NS0135X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLA06720Medicare UPIN
FLK3210Medicare PIN