=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437444817
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DERMATOLOGY ASSOCIATES OF BAY COUNTY, P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/14/2011
-----------------------------------------------------
Last Update Date | 06/16/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3025 6TH ST
-----------------------------------------------------
City | MARIANNA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32446-1930
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-769-1668
-----------------------------------------------------
Fax | 850-785-2123
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1900 HARRISON AVE
-----------------------------------------------------
City | PANAMA CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32405-4542
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-769-1668
-----------------------------------------------------
Fax | 850-785-2123
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. ROBERT JOHN SIRAGUSA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 850-769-1668
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207ND0101X
-----------------------------------------------------
Taxonomy Name | MOHS-Micrographic Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------