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General NPI Number Information
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NPI Number | 1154422558
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Entity Type | Organization
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Legal Business Name | NORTHEAST DERMATOLOGY, PA
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Dates
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Enumeration Date | 09/26/2006
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Last Update Date | 03/07/2023
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Provider Practice Location Address
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Address Line | 220 GRACES WAY
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City | COLUMBIA
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State | SC
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Zip | 29229
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Country | US
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Telephone | 803-736-4560
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Fax | 803-744-1217
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Provider Business Mailing Address
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Address Line | 220 GRACES WAY
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City | COLUMBIA
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State | SC
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Zip | 29229
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Country | US
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Telephone | 803-736-4560
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Fax | 803-744-1217
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. LEE SMITH CARSON
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Credential | M.D.
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Telephone | 803-736-4560
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | 22975
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License Number State | SC
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