Provider Demographics
NPI:1154344547
Name:SOUTH CAROLINA SKIN CANCER CENTER
Entity type:Organization
Organization Name:SOUTH CAROLINA SKIN CANCER CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:R
Authorized Official - Last Name:DEBLOOM
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:864-288-1154
Mailing Address - Street 1:300 ASHBY PARK LANE
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-6903
Mailing Address - Country:US
Mailing Address - Phone:864-288-1154
Mailing Address - Fax:864-288-2554
Practice Address - Street 1:300 ASHBY PARK LANE
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-6903
Practice Address - Country:US
Practice Address - Phone:864-288-1154
Practice Address - Fax:864-288-2554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-26
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCTL28759207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC8573Medicare PIN