Provider Demographics
NPI:1053347203
Name:DERMATOLOGIC AND COSMETIC SURGERY
Entity type:Organization
Organization Name:DERMATOLOGIC AND COSMETIC SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:S
Authorized Official - Last Name:EBY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-936-1145
Mailing Address - Street 1:2668 SWAMP CABBAGE CT
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9332
Mailing Address - Country:US
Mailing Address - Phone:239-936-1145
Mailing Address - Fax:239-275-5074
Practice Address - Street 1:2668 SWAMP CABBAGE CT
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-9332
Practice Address - Country:US
Practice Address - Phone:239-936-1145
Practice Address - Fax:239-275-5074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-22
Last Update Date:2013-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0015824261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK7316Medicare PIN
FLF1075Medicare PIN