MEDICARE: CAMELBACK DERMATOLOGY & SKIN SURGERY, INC

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	207ND0101X	MOHS-Micrographic Surgery Physician	31198	AZ
2	207NS0135X	Procedural Dermatology Physician	31198	AZ
3	207N00000X	Dermatology Physician	31198	AZ

General Provider Information

NPI Number	:	1225175441
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAMELBACK DERMATOLOGY & SKIN SURGERY, INC

Provider Business Mailing Address
First Line	:	4512 N 40TH ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85018-3600
Country	:	US
Telephone Number	:	602-954-7546
Fax Number	:	602-952-2941

Provider Business Practice Location Address
First Line	:	4512 N 40TH ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85018-3600
Country	:	US
Telephone Number	:	602-954-7546
Fax Number	:	602-952-2941

Authorized Official
Title or Position	:	PRACTICE ADMINISTRATOR
Name	:	JEFFREY LEE ROMINE
Credential	:
Telephone Number	:	602-954-7546

Provider Enumeration Date	:	01/30/2007
Last Update Date	:	11/14/2014

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