Healthcare Provider Details

I. General information

NPI: 1083693857
Provider Name (Legal Business Name): CAROLINA DERMATOLOGY GRP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2006
Last Update Date: 07/16/2024
Certification Date: 07/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1706 ST JULIANS PLACE
COLUMBIA SC
29204-2410
US

IV. Provider business mailing address

1706 ST JULIANS PLACE
COLUMBIA SC
29204-2410
US

V. Phone/Fax

Practice location:
  • Phone: 803-771-7506
  • Fax: 803-771-9455
Mailing address:
  • Phone: 803-771-7506
  • Fax: 803-771-9455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number StateSC

VIII. Authorized Official

Name: ANGELA K GRANT
Title or Position: OFFICE MANAGER
Credential:
Phone: 803-771-7506