Basic Information
| Provider Information | |||||||||
| NPI: | 1447911938 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVANCED DERMATOLOGY OF SC PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 151 SOUTHHALL LN STE 300 | ||||||||
| Address2: | |||||||||
| City: | MAITLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327517172 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 0791772934 | ||||||||
| FaxNumber: | 4076503455 | ||||||||
| Practice Location | |||||||||
| Address1: | 1700 FIRST BAXTER XING STE 101 | ||||||||
| Address2: | |||||||||
| City: | FORT MILL | ||||||||
| State: | SC | ||||||||
| PostalCode: | 297088950 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8038023376 | ||||||||
| FaxNumber: | 8038023329 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2022 | ||||||||
| LastUpdateDate: | 01/06/2022 | ||||||||
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| AuthorizedOfficialLastName: | DECLUE | ||||||||
| AuthorizedOfficialFirstName: | AMY | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR PROVIDER ENROLLMENT | ||||||||
| AuthorizedOfficialTelephone: | 4079177293 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ADVANCED DERMATOLOGY OF SC PC | ||||||||
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| NPICertificationDate: | 01/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.