Provider Demographics
NPI:1215911383
Name:SOUTH COAST DERMATOLOGY LLC
Entity type:Organization
Organization Name:SOUTH COAST DERMATOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:DEGIACOMO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:781-335-9700
Mailing Address - Street 1:90 LIBBEY PKWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WEYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02189-3100
Mailing Address - Country:US
Mailing Address - Phone:781-335-9700
Mailing Address - Fax:781-335-9709
Practice Address - Street 1:90 LIBBEY PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:WEYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02189-3100
Practice Address - Country:US
Practice Address - Phone:781-335-9700
Practice Address - Fax:781-335-9709
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-02
Last Update Date:2018-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
M17965OtherBC/BS
691531OtherTUFTS
MA9713361Medicaid
M17965OtherBC/BS
691531OtherTUFTS