MEDICARE: SKIN SURGERY CENTER PA

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	207ND0101X	MOHS-Micrographic Surgery Physician	29232	SC

General Provider Information

NPI Number	:	1851810279
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SKIN SURGERY CENTER PA

Provider Business Mailing Address
First Line	:	1450 PROFESSIONAL PARK DR STE 150
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27103-1307
Country	:	US
Telephone Number	:	336-607-8061
Fax Number	:	336-724-6123

Provider Business Practice Location Address
First Line	:	180 WINGO WAY STE 202
Second Line	:
City	:	MOUNT PLEASANT
State	:	SC
Zip	:	29464-1811
Country	:	US
Telephone Number	:	843-790-1777
Fax Number	:	843-790-1790

Authorized Official
Title or Position	:	DIRECTOR OF OPERATIONS
Name	:	MISS JAMIE L HOPKINS
Credential	:
Telephone Number	:	336-607-8061

Provider Enumeration Date	:	09/18/2017
Last Update Date	:	09/18/2017

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