=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447272398
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEDICAL AND COSMETIC DERMATOLOGY OF CAPE COD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/23/2006
-----------------------------------------------------
Last Update Date | 10/23/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 700 ATTUCKS LN
-----------------------------------------------------
City | HYANNIS
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02601-1809
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-771-7790
-----------------------------------------------------
Fax | 508-771-7793
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 845963
-----------------------------------------------------
City | BOSTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02284
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-771-7790
-----------------------------------------------------
Fax | 508-771-7793
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN PRESIDENT
-----------------------------------------------------
Name | DR. STEVEN ISRAEL MORENO
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 508-771-7790
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------