1821205097 NPI number — BEAUFORT DERMATOLOGY PC

Table of content: (NPI 1821205097)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821205097 NPI number — BEAUFORT DERMATOLOGY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BEAUFORT DERMATOLOGY PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1821205097
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1096 RIBAUT ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BEAUFORT
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29902
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-524-5550
Provider Business Mailing Address Fax Number:
842-524-6798

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1096 RIBAUT ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BEAUFORT
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29902
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-524-5550
Provider Business Practice Location Address Fax Number:
842-524-6798
Provider Enumeration Date:
05/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BREWER
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
C
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
843-524-5550

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , with the licence number:  17632 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207NP0225X , with the licence number: 17636 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 6P1193 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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