1427221605 NPI number — ACUTE DERMATOLOGY CLINIC PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427221605 NPI number — ACUTE DERMATOLOGY CLINIC PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ACUTE DERMATOLOGY CLINIC 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:
1427221605
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/27/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 101295
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAPE CORAL
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33910-1295
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-482-7546
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9400 GLADIOLUS DR
Provider Second Line Business Practice Location Address:
SUITE 320
Provider Business Practice Location Address City Name:
FORT MYERS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33908-6699
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-482-7546
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/08/2008

Additional Information

Authorized Official

Authorized Official Last Name:
VU
Authorized Official First Name:
CHAU
Authorized Official Middle Name:
PAULINA
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
239-482-7546

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  OS9425 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: AJ932 . This is a "MEDICARE PTAN" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 274238100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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