Healthcare Provider Details

I. General information

NPI: 1811005341
Provider Name (Legal Business Name): MID-FLORIDA SKIN CANCER CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 09/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 N WESTMONTE DR SUITE A
ALTAMONTE SPRINGS FL
32714
US

IV. Provider business mailing address

220 N WESTMONTE DR SUITE A
ALTAMONTE SPRINGS FL
32714
US

V. Phone/Fax

Practice location:
  • Phone: 407-788-8900
  • Fax: 407-788-8834
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberME34331
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberME34331
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207NI0002X
TaxonomyClinical & Laboratory Dermatological Immunology Physician
License NumberME34331
License Number StateFL

VIII. Authorized Official

Name: DR. RANDALL B COVERMAN
Title or Position: PRESIDENT
Credential: MD
Phone: 407-788-8900