=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982783270
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DERMATOLOGY SURGERY CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/06/2006
-----------------------------------------------------
Last Update Date | 05/18/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15 HOSPITAL CENTER BLVD STE 2
-----------------------------------------------------
City | HILTON HEAD
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29926
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-689-9200
-----------------------------------------------------
Fax | 843-689-9201
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15 HOSPITAL CENTER BLVD STE 2
-----------------------------------------------------
City | HILTON HEAD
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29926
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-689-9200
-----------------------------------------------------
Fax | 843-689-9201
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE OFFICER
-----------------------------------------------------
Name | DR. A THOMAS BUNDY
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 843-689-9200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------