MEDICARE: COASTAL DERMATOLOGY INSTITUTE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207ND0101X	MOHS-Micrographic Surgery Physician

General Provider Information

NPI Number	:	1174122444
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COASTAL DERMATOLOGY INSTITUTE LLC

Provider Business Mailing Address
First Line	:	199 VILLAGE CENTER BLVD STE 200
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29579-3589
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	199 VILLAGE CENTER BLVD STE 200
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29579-3589
Country	:	US
Telephone Number	:	843-738-0500
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MICHAEL CENTILLI
Credential	:	DO
Telephone Number	:	517-203-6532

Provider Enumeration Date	:	10/19/2020
Last Update Date	:	06/02/2021

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