Healthcare Provider Details

I. General information

NPI: 1134896467
Provider Name (Legal Business Name): ID OF PLYMOUTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2021
Last Update Date: 08/25/2021
Certification Date: 08/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 LONG POND RD STE 202
PLYMOUTH MA
02360-2642
US

IV. Provider business mailing address

4700 EXCHANGE CT STE 110
BOCA RATON FL
33431-4450
US

V. Phone/Fax

Practice location:
  • Phone: 508-747-4424
  • Fax:
Mailing address:
  • Phone: 561-314-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: JENNIFER T HALEY
Title or Position: AUTHORIZED GROUP OFFICIAL
Credential: MD
Phone: 561-314-2000