Provider Demographics
NPI:1336448836
Name:DERMATOLOGY ASSOCIATES OF BAY COUNTY, P.A.
Entity Type:Organization
Organization Name:DERMATOLOGY ASSOCIATES OF BAY COUNTY, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:SIRAGUSA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-769-1668
Mailing Address - Street 1:1900 HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-4542
Mailing Address - Country:US
Mailing Address - Phone:850-769-1668
Mailing Address - Fax:850-785-2123
Practice Address - Street 1:101 PROFESSIONAL LN
Practice Address - Street 2:
Practice Address - City:ENTERPRISE
Practice Address - State:AL
Practice Address - Zip Code:36330-2085
Practice Address - Country:US
Practice Address - Phone:334-347-3404
Practice Address - Fax:334-671-0344
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DERMATOLOGY ASSOCIATES OF BAY COUNTY, P.A.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-03-23
Last Update Date:2011-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000164600Medicaid
FLCB7612OtherRR MEDICARE
FLCB7612OtherRR MEDICARE