Healthcare Provider Details

I. General information

NPI: 1851575252
Provider Name (Legal Business Name): PETER J SUKIN MD INC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2007
Last Update Date: 03/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9326 A MEDICAL PLAZA DRIVE
N CHARLESTON SC
29406-9138
US

IV. Provider business mailing address

9326 A MEDICAL PLAZA DRIVE
N CHARLESTON SC
29406-9138
US

V. Phone/Fax

Practice location:
  • Phone: 843-377-1600
  • Fax: 843-377-1601
Mailing address:
  • Phone: 843-377-1600
  • Fax: 843-377-1601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number22504
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number22504
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number22504
License Number StateSC
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number22504
License Number StateSC
# 5
Primary TaxonomyY
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number22504
License Number StateSC

VIII. Authorized Official

Name: LYN INMAN
Title or Position: BILLING AGENT
Credential:
Phone: 843-377-1600