MEDICARE: WATER'S EDGE DERMATOLOGY

Medicare Provider Information

Scope of Practice

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

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

General Provider Information

NPI Number	:	1477906857
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WATER'S EDGE DERMATOLOGY

Provider Business Mailing Address
First Line	:	2845 PGA BLVD
Second Line	:
City	:	PALM BEACH GARDENS
State	:	FL
Zip	:	33410-2910
Country	:	US
Telephone Number	:	561-693-0540
Fax Number	:	561-422-4212

Provider Business Practice Location Address
First Line	:	7605 CONROY WINDERMERE RD
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32835-2646
Country	:	US
Telephone Number	:	561-693-0540
Fax Number	:	561-422-4212

Authorized Official
Title or Position	:	BILLING DIRECTOR
Name	:	AMANDA MITCHELL
Credential	:
Telephone Number	:	561-693-0540

Provider Enumeration Date	:	07/20/2016
Last Update Date	:	07/20/2016

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