MEDICARE: SPACE COAST DERMATOLOGY CLINIC, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1043423189
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPACE COAST DERMATOLOGY CLINIC, PLLC

Provider Business Mailing Address
First Line	:	695 CONE PARK CT
Second Line	:
City	:	MERRITT ISLAND
State	:	FL
Zip	:	32952-3755
Country	:	US
Telephone Number	:	321-453-3360
Fax Number	:	321-453-4586

Provider Business Practice Location Address
First Line	:	695 CONE PARK CT
Second Line	:
City	:	MERRITT ISLAND
State	:	FL
Zip	:	32952-3755
Country	:	US
Telephone Number	:	321-453-3360
Fax Number	:	321-453-4586

Authorized Official
Title or Position	:	PARTNER
Name	:	DR. JAMES A EARHART
Credential	:	M.D.
Telephone Number	:	321-453-3360

Provider Enumeration Date	:	05/07/2007
Last Update Date	:	11/18/2010

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