MEDICARE: FLORIDA SPECIALTY DERMATOLOGY CARE LLC

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	363L00000X	Nurse Practitioner
2	207ND0900X	Dermatopathology Physician

General Provider Information

NPI Number	:	1881940898
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FLORIDA SPECIALTY DERMATOLOGY CARE LLC

Provider Business Mailing Address
First Line	:	400 N TAMPA ST
Second Line	:	SUITE: 1100
City	:	TAMPA
State	:	FL
Zip	:	33602-4719
Country	:	US
Telephone Number	:	813-275-9100
Fax Number	:	813-275-9201

Provider Business Practice Location Address
First Line	:	400 N TAMPA ST
Second Line	:	SUITE: 1100
City	:	TAMPA
State	:	FL
Zip	:	33602-4719
Country	:	US
Telephone Number	:	813-275-9100
Fax Number	:	813-275-9201

Authorized Official
Title or Position	:	CHIEF NURSING OFFICER
Name	:	DEBRA M SHELBY
Credential	:
Telephone Number	:	813-275-9100

Provider Enumeration Date	:	07/27/2012
Last Update Date	:	07/27/2012

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