=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205024304
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SKIN CANCER SPECIALIST, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/15/2007
-----------------------------------------------------
Last Update Date | 10/31/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5575 MARQUESAS CIR
-----------------------------------------------------
City | SARASOTA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34233-3332
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-924-8080
-----------------------------------------------------
Fax | 941-924-8089
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5575 MARQUESAS CIR
-----------------------------------------------------
City | SARASOTA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34233-3332
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-924-8080
-----------------------------------------------------
Fax | 941-924-8089
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE ADMINISTRATOR
-----------------------------------------------------
Name | APRIL KELLY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 941-924-8080
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number | ME81031
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------