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General NPI Number Information
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NPI Number | 1386985950
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Entity Type | Organization
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Legal Business Name | ALLERGY DERMATOLOGY & SKIN CANCER CENTER INC
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Dates
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Enumeration Date | 03/07/2013
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Last Update Date | 03/07/2013
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Provider Practice Location Address
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Address Line | 9580 S FEDERAL HWY
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City | PORT SAINT LUCIE
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State | FL
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Zip | 34952-4217
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Country | US
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Telephone | 772-335-1500
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Fax |
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Provider Business Mailing Address
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Address Line | 9580 S FEDERAL HWY
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City | PORT SAINT LUCIE
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State | FL
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Zip | 34952-4217
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Country | US
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Telephone | 772-335-1500
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. GARY L MARDER
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Credential | D.O
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Telephone | 772-335-1500
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | OS4773
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License Number State | FL
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