| Entity Name: | SUNSHINE STATE DERMATOLOGY AND SKIN CANCER CENTER INC. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Active |
| Date Filed: | 12 Dec 2022 (2 years ago) |
| Document Number: | P22000092004 |
| FEI/EIN Number | 921321379 |
| Mail Address: | 1415 EAST VENICE AVENUE, VENICE, FL, 34292, US |
| Address: | 12497 TAMIAMI TRAIL S, NORTH PORT, FL, 34287, US |
| ZIP code: | 34287 |
| County: | Sarasota |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1164122347 | 2023-03-07 | 2024-07-31 | 88 SUGAR MILL DR, OSPREY, FL, 342299077, US | 12497 TAMIAMI TRL S, UNIT 1, NORTH PORT, FL, 342871415, US | |||||||||||||||||||||||||||||||||||
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| Phone | +1 941-228-9183 |
| Phone | +1 941-282-3376 |
| Fax | 9412823378 |
Authorized person
| Name | DR. ADAM S GREENBERG |
| Role | PRESIDENT |
| Phone | 9412823376 |
Taxonomy
| Taxonomy Code | 207N00000X - Dermatology Physician |
| Is Primary | No |
| Taxonomy Code | 207ND0101X - MOHS-Micrographic Surgery Physician |
| Is Primary | Yes |
| Taxonomy Code | 207NP0225X - Pediatric Dermatology Physician |
| Is Primary | No |
Other Provider Identifiers
| Issuer | BCBS PAYER ID |
| Number | YCEA9 |
| State | FL |
| Issuer | NPI |
| Number | 1932193729 |
| Name | Role | Address |
|---|---|---|
| GREENBERG ADAM S | Agent | 1415 EAST VENICE AVENUE, VENICE, FL, 34292 |
| Name | Role | Address |
|---|---|---|
| GREENBERG ADAM SMD | President | 12497 TAMIAMI TRAIL S, NORTH PORT, FL, 34287 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF MAILING ADDRESS | 2024-10-04 | 12497 TAMIAMI TRAIL S, UNIT 1, NORTH PORT, FL 34287 | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2024-10-04 | 1415 EAST VENICE AVENUE, VENICE, FL 34292 | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2023-07-17 | 12497 TAMIAMI TRAIL S, UNIT 1, NORTH PORT, FL 34287 | No data |
| Name | Date |
|---|---|
| AMENDED ANNUAL REPORT | 2024-12-06 |
| AMENDED ANNUAL REPORT | 2024-10-04 |
| ANNUAL REPORT | 2024-01-23 |
| Domestic Profit | 2022-12-12 |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
