Healthcare Provider Details

I. General information

NPI: 1952800112
Provider Name (Legal Business Name): PREMIER DERMATOLOGY OF FLORIDA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2018
Last Update Date: 01/30/2024
Certification Date: 01/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 WHITEHALL DR UNIT 117
ST AUGUSTINE FL
32086-5266
US

IV. Provider business mailing address

109 WHITEHALL DR UNIT 117
ST AUGUSTINE FL
32086-5266
US

V. Phone/Fax

Practice location:
  • Phone: 904-460-2388
  • Fax: 904-460-2689
Mailing address:
  • Phone: 904-460-2388
  • Fax: 904-460-2689

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JOANNA LEE MCGETRICK
Title or Position: OWNER
Credential: MD
Phone: 863-258-0601