Provider Demographics
NPI:1770608937
Name:COAST DERMATOLOGY AND SKIN CANCER CENTER PA
Entity type:Organization
Organization Name:COAST DERMATOLOGY AND SKIN CANCER CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSCIAN
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:GREGORY
Authorized Official - Last Name:NEILY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:941-493-7400
Mailing Address - Street 1:21550 ANGELA LN
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34293-2017
Mailing Address - Country:US
Mailing Address - Phone:941-493-7400
Mailing Address - Fax:941-493-1940
Practice Address - Street 1:21550 ANGELA LN
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34293-2017
Practice Address - Country:US
Practice Address - Phone:941-493-7400
Practice Address - Fax:941-493-1940
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2009-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS0006785174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL99100OtherBLUE SHIELD GROUP NUMBER
FL99100OtherBLUE SHIELD GROUP NUMBER
FLE82043Medicare UPIN