Provider Demographics
NPI:1386985950
Name:ALLERGY DERMATOLOGY & SKIN CANCER CENTER INC
Entity type:Organization
Organization Name:ALLERGY DERMATOLOGY & SKIN CANCER CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:L
Authorized Official - Last Name:MARDER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:772-335-1500
Mailing Address - Street 1:9580 S FEDERAL HWY
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-4217
Mailing Address - Country:US
Mailing Address - Phone:772-335-1500
Mailing Address - Fax:
Practice Address - Street 1:9580 S FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-4217
Practice Address - Country:US
Practice Address - Phone:772-335-1500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-07
Last Update Date:2013-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS4773261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD60722Medicare UPIN