MEDICARE: DR. TERRENCE ALLAN CRONIN SR. MD

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	207NS0135X	Procedural Dermatology Physician	ME0019430	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	05291	OTHER	FL	FLORIDA BLUE SHIELD

General Provider Information

NPI Number	:	1548262140
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TERRENCE ALLAN CRONIN SR. MD

Provider Business Mailing Address
First Line	:	1399 S HARBOR CITY BLVD
Second Line	:
City	:	MELBOURNE
State	:	FL
Zip	:	32901-3208
Country	:	US
Telephone Number	:	321-726-1711
Fax Number	:	321-726-1715

Provider Business Practice Location Address
First Line	:	1399 S HARBOR CITY BLVD
Second Line	:
City	:	MELBOURNE
State	:	FL
Zip	:	32901-3208
Country	:	US
Telephone Number	:	321-726-1711
Fax Number	:	321-726-1715

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/12/2005
Last Update Date	:	07/08/2007

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