Organization
SOUTHERN DERMATOLOGY CENTER, PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. ANGELO MANCUSO DO (OWNER)
(256) 351-9077
Entity
Organization
Contact information
Practice address
2828 HIGHWAY 31 S, SUITE 105, DECATUR, AL 35603-1510
(256) 351-9077
(256) 351-0294
Mailing address
2828 HIGHWAY 31 S, SUITE 105, DECATUR, AL 35603-1510
(256) 351-9077
(256) 351-0294
Taxonomy
Speciality
Code
Description
License number
State
207N00000X
Dermatology Physician
Primary
D0196
AL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
051080875
BLUE CROSS ID#
AL
Enumeration date
07/09/2006
Last updated
04/07/2009
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