Provider Demographics
NPI:1053675660
Name:DERMATOLOGY ASSOCIATES OF BAY COUNTY, PA
Entity type:Organization
Organization Name:DERMATOLOGY ASSOCIATES OF BAY COUNTY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT DERMATOLOGY ASSOCIATES
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:SIRAGUSA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-769-1668
Mailing Address - Street 1:1900 HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-4542
Mailing Address - Country:US
Mailing Address - Phone:850-769-1668
Mailing Address - Fax:850-785-2123
Practice Address - Street 1:20370 NE BURNS AVE
Practice Address - Street 2:
Practice Address - City:BLOUNTSTOWN
Practice Address - State:FL
Practice Address - Zip Code:32424-1045
Practice Address - Country:US
Practice Address - Phone:850-769-7546
Practice Address - Fax:850-785-2123
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-28
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME23244207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000164600Medicaid