Basic Information
| Provider Information | |||||||||
| NPI: | 1255754008 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVANCED DERMATOLOGY OF SC PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 151 SOUTHHALL LN | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | MAITLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327517176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4078752080 | ||||||||
| FaxNumber: | 4076503455 | ||||||||
| Practice Location | |||||||||
| Address1: | 1410B JOHN B WHITE SR BLVD | ||||||||
| Address2: | |||||||||
| City: | SPARTANBURG | ||||||||
| State: | SC | ||||||||
| PostalCode: | 293063927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8648740017 | ||||||||
| FaxNumber: | 8645746088 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2014 | ||||||||
| LastUpdateDate: | 01/30/2014 | ||||||||
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| AuthorizedOfficialLastName: | LEAVITT | ||||||||
| AuthorizedOfficialFirstName: | MATT | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4078752080 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.