Healthcare Provider Details

I. General information

NPI: 1356898324
Provider Name (Legal Business Name): WATERS EDGE DERMATOLOGY GLOBAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2016
Last Update Date: 09/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2601 S KANNER HIGHWAY
STUART FL
34994
US

IV. Provider business mailing address

600 VILLAGE SQUARE XING
PALM BEACH GARDENS FL
33410-4543
US

V. Phone/Fax

Practice location:
  • Phone: 561-693-0540
  • Fax:
Mailing address:
  • Phone: 561-693-0540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: THEODORE SCHIFF
Title or Position: MANAGER
Credential: MD
Phone: 561-693-0540