Provider Demographics
NPI:1699733238
Name:DERSCH, STEPHEN ANDREW (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:ANDREW
Last Name:DERSCH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 603898
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-3898
Mailing Address - Country:US
Mailing Address - Phone:843-792-6200
Mailing Address - Fax:
Practice Address - Street 1:805 PAMPLICO HWY STE B135
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29505-6047
Practice Address - Country:US
Practice Address - Phone:843-674-6414
Practice Address - Fax:843-674-2642
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC22678207QA0505X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC226785Medicaid
SCP00103192OtherRAILROAD MEDICARE- PROVIDER NUMBER
SCGP4840OtherMEDICAID GROUP
SCCN2547OtherRAILROAD MEDICARE- GROUP NUMBER
SC7718Medicare PIN
SCP00103192OtherRAILROAD MEDICARE- PROVIDER NUMBER
SCH501007718Medicare PIN
SCGP4840OtherMEDICAID GROUP
SCH50100Medicare UPIN