Provider Demographics
NPI:1528176146
Name:SKIN WELLNESS CENTER P A
Entity type:Organization
Organization Name:SKIN WELLNESS CENTER P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT DERMATOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MELANIE
Authorized Official - Middle Name:R
Authorized Official - Last Name:HAYNES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-545-3376
Mailing Address - Street 1:PO BOX 1548
Mailing Address - Street 2:
Mailing Address - City:PINELLAS PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33780-1548
Mailing Address - Country:US
Mailing Address - Phone:727-545-3376
Mailing Address - Fax:727-545-5003
Practice Address - Street 1:9005 BELCHER RD
Practice Address - Street 2:
Practice Address - City:PINELLAS PARK
Practice Address - State:FL
Practice Address - Zip Code:33782-4423
Practice Address - Country:US
Practice Address - Phone:727-545-3376
Practice Address - Fax:727-545-5003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2008-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME48813207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL12272OtherBLUE CROSS BLUE SHIELD
FLAS20877590001OtherCIGNA VENDOR NUMBER
FL1081799OtherAETNA
FL1081799OtherAETNA
FLAS20877590001OtherCIGNA VENDOR NUMBER
FLDE4723Medicare PIN