MEDICARE: DERMATOLOGY OF CAPE COD, PC

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	174400000X	Specialist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	695562	OTHER	MA	TUFTS
2	M18770	OTHER	MA	BC BS
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	4190	OTHER	MA	HARVARD PILGRIM

General Provider Information

NPI Number	:	1386868438
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DERMATOLOGY OF CAPE COD, PC

Provider Business Mailing Address
First Line	:	37 EDGERTON DR
Second Line	:
City	:	NORTH FALMOUTH
State	:	MA
Zip	:	02556-2821
Country	:	US
Telephone Number	:	508-563-2550
Fax Number	:	508-563-2570

Provider Business Practice Location Address
First Line	:	37 EDGERTON DR
Second Line	:
City	:	NORTH FALMOUTH
State	:	MA
Zip	:	02556-2821
Country	:	US
Telephone Number	:	508-563-2550
Fax Number	:	508-563-2570

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MARK LISKA
Credential	:	M.D.
Telephone Number	:	508-563-2550

Provider Enumeration Date	:	04/12/2007
Last Update Date	:	03/20/2009

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