=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548432719
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOBILE DERMATOLOGY, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/28/2008
-----------------------------------------------------
Last Update Date | 12/17/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6163 OMNI PARK DR
-----------------------------------------------------
City | MOBILE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36609-5195
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 251-635-1315
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6163 OMNI PARK DR
-----------------------------------------------------
City | MOBILE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36609-5195
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 251-635-1315
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHAIRMAN
-----------------------------------------------------
Name | DR. JOHN SCOTT VANLOOCK
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 251-635-1315
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number | 23602
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------