MEDICARE: ALLERGY DERMATOLOGY & SKIN CANCER CENTER 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	261QM2500X	Medical Specialty Clinic/Center	OS4773	FL

General Provider Information

NPI Number	:	1386985950
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALLERGY DERMATOLOGY & SKIN CANCER CENTER INC

Provider Business Mailing Address
First Line	:	9580 S FEDERAL HWY
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34952-4217
Country	:	US
Telephone Number	:	772-335-1500
Fax Number	:

Provider Business Practice Location Address
First Line	:	9580 S FEDERAL HWY
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34952-4217
Country	:	US
Telephone Number	:	772-335-1500
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. GARY L MARDER
Credential	:	D.O
Telephone Number	:	772-335-1500

Provider Enumeration Date	:	03/07/2013
Last Update Date	:	03/07/2013

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