=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659176287
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE DERMATOLOGY GROUP OF FLORIDA PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/18/2025
-----------------------------------------------------
Last Update Date | 02/18/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 137 NW 100TH AVE
-----------------------------------------------------
City | PLANTATION
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33324-7034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-577-5161
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4000 HOLLYWOOD BLVD STE 215S
-----------------------------------------------------
City | HOLLYWOOD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33021-1227
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 844-633-9358
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | RCM VP
-----------------------------------------------------
Name | NANCY SEGUIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 954-237-7090
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------