Healthcare Provider Details

I. General information

NPI: 1174604409
Provider Name (Legal Business Name): SOUTH CHARLESTON DERMATOLOGY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 12/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4815 KANAWHA AVE SW
SOUTH CHARLESTON WV
25309-1207
US

IV. Provider business mailing address

4815 KANAWHA AVE SW
SOUTH CHARLESTON WV
25309-1207
US

V. Phone/Fax

Practice location:
  • Phone: 304-768-4567
  • Fax: 304-768-2277
Mailing address:
  • Phone: 304-768-4567
  • Fax: 304-768-2277

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number2097
License Number StateWV

VIII. Authorized Official

Name: MRS. MICHELLE LEIGH ENDICOTT
Title or Position: OWNER/PHYSICIAN
Credential: DO
Phone: 304-768-4567