Healthcare Provider Details

I. General information

NPI: 1942637772
Provider Name (Legal Business Name): PREMIER DERMATOLOGY AND SKIN CANCER CENTER, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2013
Last Update Date: 10/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5935 WASHINGTON AVE SUITE A
OCEAN SPRINGS MS
39564-2642
US

IV. Provider business mailing address

5935 WASHINGTON AVE SUITE A
OCEAN SPRINGS MS
39564-2642
US

V. Phone/Fax

Practice location:
  • Phone: 228-215-0669
  • Fax: 228-215-0669
Mailing address:
  • Phone: 228-215-0669
  • Fax: 228-215-0669

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number21095
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number21095
License Number StateMS

VIII. Authorized Official

Name: MICHELE HUGHES
Title or Position: PHYSICIAN/OWNER
Credential: M.D.
Phone: 228-215-0669