MEDICARE: BENEDETTO DERMATOLOGY,LLC

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	261QA1903X	Ambulatory Surgical Clinic/Center	04841500	PA

General Provider Information

NPI Number	:	1811938863
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BENEDETTO DERMATOLOGY,LLC

Provider Business Mailing Address
First Line	:	1200 LOCUST ST
Second Line	:	DERMATOLOGIC SURGICENTER
City	:	PHILADELPHIA
State	:	PA
Zip	:	19107-5605
Country	:	US
Telephone Number	:	215-546-3666
Fax Number	:	215-546-6060

Provider Business Practice Location Address
First Line	:	1200 LOCUST ST
Second Line	:	DERMATOLOGIC SURGICENTER
City	:	PHILADELPHIA
State	:	PA
Zip	:	19107-5605
Country	:	US
Telephone Number	:	215-546-3666
Fax Number	:	215-546-6060

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DR. ANTHONY V BENEDETTO
Credential	:	D.O.
Telephone Number	:	215-546-3666

Provider Enumeration Date	:	06/09/2006
Last Update Date	:	12/16/2014

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