Healthcare Provider Details

I. General information

NPI: 1821205097
Provider Name (Legal Business Name): BEAUFORT DERMATOLOGY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 10/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1096 RIBAUT ROAD
BEAUFORT SC
29902
US

IV. Provider business mailing address

1096 RIBAUT ROAD
BEAUFORT SC
29902
US

V. Phone/Fax

Practice location:
  • Phone: 843-524-5550
  • Fax: 842-524-6798
Mailing address:
  • Phone: 843-524-5550
  • Fax: 842-524-6798

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number17632
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License Number17636
License Number StateSC

VIII. Authorized Official

Name: DR. PAUL C BREWER
Title or Position: OWNER
Credential: MD
Phone: 843-524-5550