Healthcare Provider Details

I. General information

NPI: 1427087089
Provider Name (Legal Business Name): DERMATOLOGY ASSOCIATES OF THE LOWCOUNTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 12/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 OKATIE CENTER BLVD S SUITE 210
BLUFFTON SC
29909-7507
US

IV. Provider business mailing address

3901 MAIN ST SUITE D
HILTON HEAD ISLAND SC
29926-4614
US

V. Phone/Fax

Practice location:
  • Phone: 843-689-5259
  • Fax: 843-689-3797
Mailing address:
  • Phone: 843-689-5259
  • Fax: 843-689-3797

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: DOLORES J WADE
Title or Position: ASST. MGR
Credential:
Phone: 843-689-5259