MEDICARE: ABIDE DERMATOLOGY CLINIC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician

General Provider Information

NPI Number	:	1235399213
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ABIDE DERMATOLOGY CLINIC

Provider Business Mailing Address
First Line	:	1209 S MAIN ST
Second Line	:
City	:	GREENVILLE
State	:	MS
Zip	:	38701-6342
Country	:	US
Telephone Number	:	662-335-3847
Fax Number	:

Provider Business Practice Location Address
First Line	:	1209 S MAIN ST
Second Line	:
City	:	GREENVILLE
State	:	MS
Zip	:	38701-6342
Country	:	US
Telephone Number	:	662-335-3847
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JOHN M ABIDE
Credential	:
Telephone Number	:	662-335-3847

Provider Enumeration Date	:	06/12/2008
Last Update Date	:	06/12/2008

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Directions to “ABIDE DERMATOLOGY CLINIC ” Practice Location

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