Provider Demographics
NPI:1306072566
Name:WEIMER SKIN CLINIC, P.A.
Entity type:Organization
Organization Name:WEIMER SKIN CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:WEIMER
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:843-839-1414
Mailing Address - Street 1:1240 21ST AVENUE N.
Mailing Address - Street 2:SUITE 106
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29577-7431
Mailing Address - Country:US
Mailing Address - Phone:843-839-1414
Mailing Address - Fax:843-839-1413
Practice Address - Street 1:1240 21ST AVENUE N
Practice Address - Street 2:SUITE 106
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-7431
Practice Address - Country:US
Practice Address - Phone:843-839-1414
Practice Address - Fax:843-839-1413
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WEIMER SKIN CLINIC, PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-06-02
Last Update Date:2011-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCMD 11497207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty