MEDICARE: ACADEMIC ALLIANCE IN DERMATOLOGY

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	332900000X	Non-Pharmacy Dispensing Site		FL

General Provider Information

NPI Number	:	1679857452
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ACADEMIC ALLIANCE IN DERMATOLOGY

Provider Business Mailing Address
First Line	:	4238 W KENNEDY BLVD
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33609-2231
Country	:	US
Telephone Number	:	813-879-6060
Fax Number	:	813-879-3049

Provider Business Practice Location Address
First Line	:	4238 W KENNEDY BLVD
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33609-2231
Country	:	US
Telephone Number	:	813-879-6040
Fax Number	:	813-897-6049

Authorized Official
Title or Position	:	VP OF REVENUE CYCLE MANAGEMENT
Name	:	MR. TIM SCISM
Credential	:
Telephone Number	:	813-884-3091

Provider Enumeration Date	:	09/28/2011
Last Update Date	:	08/30/2019

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