=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821125584
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AMERICAN MOBILE DERMATOLOGY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/28/2007
-----------------------------------------------------
Last Update Date | 03/18/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1054 GATEWAY BLVD SUITE 110
-----------------------------------------------------
City | BOYNTON BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33426-8309
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-738-4770
-----------------------------------------------------
Fax | 561-738-9727
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1054 GATEWAY BLVD SUITE 110
-----------------------------------------------------
City | BOYNTON BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33426-8309
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-738-4770
-----------------------------------------------------
Fax | 561-738-9727
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JAMES JUDE DEVOURSNEY
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 561-738-4770
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | ME80429
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------