Healthcare Provider Details

I. General information

NPI: 1295903276
Provider Name (Legal Business Name): ADVANCED DERMATOLOGY, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2008
Last Update Date: 02/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1361 13TH AVE S SUITE 180
JACKSONVILLE BEACH FL
32250-3233
US

IV. Provider business mailing address

1361 13TH AVE S SUITE 180
JACKSONVILLE BEACH FL
32250-3233
US

V. Phone/Fax

Practice location:
  • Phone: 904-247-4300
  • Fax: 904-247-4350
Mailing address:
  • Phone: 904-247-4300
  • Fax: 904-247-4350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberME63182
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License NumberME63182
License Number StateFL

VIII. Authorized Official

Name: DR. CHRISTINE NG
Title or Position: PRESIDENT
Credential: M.D.
Phone: 904-247-4300