=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427428416
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHWEST SKIN & CANCER INSTITUTE LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/02/2015
-----------------------------------------------------
Last Update Date | 10/02/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 242 WHIPPLE ST
-----------------------------------------------------
City | PRESCOTT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86301-1787
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-778-0808
-----------------------------------------------------
Fax | 928-778-4788
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 242 WHIPPLE ST
-----------------------------------------------------
City | PRESCOTT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86301-1787
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-778-0808
-----------------------------------------------------
Fax | 928-778-4788
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/SOLE MEMBER
-----------------------------------------------------
Name | DR. ROBIN M FLECK
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 928-778-0808
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207ND0900X
-----------------------------------------------------
Taxonomy Name | Dermatopathology Physician
-----------------------------------------------------
License Number | 31062
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------