MEDICARE: SOUTHERN DERMATOLOGY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician	11685	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1821367046
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN DERMATOLOGY LLC

Provider Business Mailing Address
First Line	:	2110 WOODSIDE EXECUTIVE CT
Second Line	:
City	:	AIKEN
State	:	SC
Zip	:	29803-3809
Country	:	US
Telephone Number	:	803-644-5779
Fax Number	:

Provider Business Practice Location Address
First Line	:	2110 WOODSIDE EXECUTIVE CT
Second Line	:
City	:	AIKEN
State	:	SC
Zip	:	29803-3809
Country	:	US
Telephone Number	:	803-644-5779
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JOHN R COOK
Credential	:	M.D.
Telephone Number	:	803-644-5779

Provider Enumeration Date	:	12/16/2011
Last Update Date	:	12/16/2011

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Directions to “SOUTHERN DERMATOLOGY LLC ” Practice Location

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