Healthcare Provider Details

I. General information

NPI: 1417089376
Provider Name (Legal Business Name): GERMAIN DERMATOLOGY, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 10/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 SEACOAST PKWY SUITE 201
MOUNT PLEASANT SC
29464-8247
US

IV. Provider business mailing address

612 SEACOAST PKWY SUITE 201
MOUNT PLEASANT SC
29464-8247
US

V. Phone/Fax

Practice location:
  • Phone: 843-881-4440
  • Fax: 843-884-8540
Mailing address:
  • Phone: 843-881-4440
  • Fax: 843-884-8540

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number22169
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number22169
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number22169
License Number StateSC
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1048
License Number StateSC

VIII. Authorized Official

Name: NELDA FIELDS
Title or Position: CONSULTANT
Credential:
Phone: 843-881-4440