MEDICARE: ACADEMIC ALLIANCE IN DERMATOLOGY, INC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	207ND0900X	Dermatopathology Physician
2	207NP0225X	Pediatric Dermatology Physician
3	207NS0135X	Procedural Dermatology Physician
4	207ND0101X	MOHS-Micrographic Surgery Physician
5	207N00000X	Dermatology Physician

General Provider Information

NPI Number	:	1184291130
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ACADEMIC ALLIANCE IN DERMATOLOGY, INC

Provider Business Mailing Address
First Line	:	5210 WEBB RD
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33615-4518
Country	:	US
Telephone Number	:	813-882-9986
Fax Number	:	813-882-9849

Provider Business Practice Location Address
First Line	:	2412 CYPRESS GLEN DR STE 102
Second Line	:
City	:	WESLEY CHAPEL
State	:	FL
Zip	:	33544-4603
Country	:	US
Telephone Number	:	813-341-1480
Fax Number	:	813-528-8730

Authorized Official
Title or Position	:	PRESIDENT/OWNER
Name	:	ANGELA RUTH PETERMAN
Credential	:	MD
Telephone Number	:	410-776-0111

Provider Enumeration Date	:	06/08/2021
Last Update Date	:	04/21/2022

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