Provider Demographics
NPI:1427473073
Name:STATE WIDE DERMATOLOGY LLC
Entity type:Organization
Organization Name:STATE WIDE DERMATOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:Y
Authorized Official - Last Name:HARRELL
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:813-749-6907
Mailing Address - Street 1:17121 RAINBOW TER
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:FL
Mailing Address - Zip Code:33556-2107
Mailing Address - Country:US
Mailing Address - Phone:813-749-6907
Mailing Address - Fax:813-475-7831
Practice Address - Street 1:17121 RAINBOW TER
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:FL
Practice Address - Zip Code:33556-2107
Practice Address - Country:US
Practice Address - Phone:813-749-6907
Practice Address - Fax:813-475-7831
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-19
Last Update Date:2014-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty