Organization
SOUTHEASTERN DERMATOLOGY, PA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. MICHAEL J FORD MD (MEDICAL DIRECTOR)
(850) 422-3376
Entity
Organization
Contact information
Practice address
2040 FLEISCHMANN RD, TALLAHASSEE, FL 32308-4599
(850) 422-3376
(850) 205-7182
Mailing address
2040 FLEISCHMANN RD, TALLAHASSEE, FL 32308-4599
(850) 422-3376
(850) 205-7182
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
000595501
—
FL
01
—
10D0992605
CLIA
FL
Enumeration date
07/01/2006
Last updated
06/14/2016
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