1639398480 NPI number — ANDERSON SKIN AND CANCER CLINIC

Table of content: (NPI 1639398480)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639398480 NPI number — ANDERSON SKIN AND CANCER CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ANDERSON SKIN AND CANCER CLINIC
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:
6
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:
1639398480
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/14/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2022 CARDINAL CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANDERSON
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29621-1504
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-224-7577
Provider Business Mailing Address Fax Number:
864-225-5165

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2022 CARDINAL CIR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANDERSON
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29621-1504
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-224-7577
Provider Business Practice Location Address Fax Number:
864-225-5165
Provider Enumeration Date:
04/24/2007

Additional Information

Authorized Official

Authorized Official Last Name:
QUARTERMAN
Authorized Official First Name:
MARK
Authorized Official Middle Name:
JOHNSON
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
864-224-7577

Provider Taxonomy Codes

  • Taxonomy code: 207ND0900X , with the licence number:  16908 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2961 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2329 . This is a "MEDICARE ID" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 3937PA , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: NP2759 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: SC98802329 . This is a "MC PTAN" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: TL7847 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 404271 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: AA5766 . This is a "MC UPIN" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: PA4496 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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