Healthcare Provider Details

I. General information

NPI: 1285683003
Provider Name (Legal Business Name): MYRTLE BEACH DERMATOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2006
Last Update Date: 08/20/2024
Certification Date: 08/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1275 21ST AVE N BLDG 2
MYRTLE BEACH SC
29577-7514
US

IV. Provider business mailing address

1275 21ST AVE N BLDG 2
MYRTLE BEACH SC
29577-7514
US

V. Phone/Fax

Practice location:
  • Phone: 843-449-9140
  • Fax: 843-497-5110
Mailing address:
  • Phone: 843-449-9140
  • Fax: 843-497-5110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number19296
License Number StateSC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. RICHARD HENRY HUSSEY III
Title or Position: PARTNER
Credential: M.D.
Phone: 843-449-9410