Healthcare Provider Details

I. General information

NPI: 1881940898
Provider Name (Legal Business Name): FLORIDA SPECIALTY DERMATOLOGY CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2012
Last Update Date: 07/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N TAMPA ST SUITE: 1100
TAMPA FL
33602-4719
US

IV. Provider business mailing address

400 N TAMPA ST SUITE: 1100
TAMPA FL
33602-4719
US

V. Phone/Fax

Practice location:
  • Phone: 813-275-9100
  • Fax: 813-275-9201
Mailing address:
  • Phone: 813-275-9100
  • Fax: 813-275-9201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number
License Number State

VIII. Authorized Official

Name: DEBRA M SHELBY
Title or Position: CHIEF NURSING OFFICER
Credential:
Phone: 813-275-9100