MEDICARE: SOUTHERN MARIN DERMATOLOGY, 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	207N00000X	Dermatology Physician

General Provider Information

NPI Number	:	1487090924
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN MARIN DERMATOLOGY, INC.

Provider Business Mailing Address
First Line	:	2330 MARINSHIP WAY
Second Line	:	SUITE 370
City	:	SAUSALITO
State	:	CA
Zip	:	94965-2853
Country	:	US
Telephone Number	:	415-887-9758
Fax Number	:	415-887-9763

Provider Business Practice Location Address
First Line	:	2330 MARINSHIP WAY
Second Line	:	SUITE 370
City	:	SAUSALITO
State	:	CA
Zip	:	94965-2853
Country	:	US
Telephone Number	:	415-887-9758
Fax Number	:	415-887-9763

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ASHLEY A SMITH
Credential	:	M.D.
Telephone Number	:	415-887-9758

Provider Enumeration Date	:	05/10/2013
Last Update Date	:	05/10/2013

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