MEDICARE: DR. MICHAEL ROBERT CENTILLI D.O.

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	207N00000X	Dermatology Physician	52108	SC

General Provider Information

NPI Number	:	1215223326
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL ROBERT CENTILLI D.O.

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	:	843-738-0500
Fax Number	:	843-738-0505

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	:	437-380-5058

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/27/2011
Last Update Date	:	06/10/2021

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