Provider Demographics
NPI:1427087089
Name:DERMATOLOGY ASSOCIATES OF THE LOWCOUNTRY
Entity type:Organization
Organization Name:DERMATOLOGY ASSOCIATES OF THE LOWCOUNTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASST. MGR
Authorized Official - Prefix:
Authorized Official - First Name:DOLORES
Authorized Official - Middle Name:J
Authorized Official - Last Name:WADE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-689-5259
Mailing Address - Street 1:3901 MAIN ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:HILTON HEAD ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29926-4614
Mailing Address - Country:US
Mailing Address - Phone:843-689-5259
Mailing Address - Fax:843-689-3797
Practice Address - Street 1:40 OKATIE CENTER BLVD S
Practice Address - Street 2:SUITE 210
Practice Address - City:BLUFFTON
Practice Address - State:SC
Practice Address - Zip Code:29909-7507
Practice Address - Country:US
Practice Address - Phone:843-689-5259
Practice Address - Fax:843-689-3797
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DERMATOLOGY ASSOCIATES OF THE LOWCOUNTRY, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-03
Last Update Date:2008-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC112194Medicaid
SC4053Medicare PIN