1730567504 NPI number — DERMATOLOGY ASSOCIATES OF TALLAHASSEE, PA

Table of content: (NPI 1730567504)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730567504 NPI number — DERMATOLOGY ASSOCIATES OF TALLAHASSEE, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DERMATOLOGY ASSOCIATES OF TALLAHASSEE, PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1730567504
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 13834
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TALLAHASSEE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32317-3834
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-205-6232
Provider Business Mailing Address Fax Number:
850-402-9130

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4233 CAMELOT XING
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VALDOSTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31602-6926
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
229-469-4383
Provider Business Practice Location Address Fax Number:
229-469-4584
Provider Enumeration Date:
05/13/2015

Additional Information

Authorized Official

Authorized Official Last Name:
RICHARDSON
Authorized Official First Name:
STEPHEN
Authorized Official Middle Name:
Authorized Official Title or Position:
BOARD SECRETARY
Authorized Official Telephone Number:
850-877-4134

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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