Healthcare Provider Details

I. General information

NPI: 1851532683
Provider Name (Legal Business Name): BEACHSIDE DERMATOLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2009
Last Update Date: 06/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2571 W EAU GALLIE BLVD SUITE 2
MELBOURNE FL
32935-8954
US

IV. Provider business mailing address

2571 W EAU GALLIE BLVD SUITE 2
MELBOURNE FL
32935-8954
US

V. Phone/Fax

Practice location:
  • Phone: 321-777-9091
  • Fax:
Mailing address:
  • Phone: 321-777-9091
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. ROSALIND A FREAS
Title or Position: PHYSICIAN
Credential: MD
Phone: 321-773-1266