Provider Demographics
NPI:1003009390
Name:DERMATOPATHOLOGY SPECIALISTS JIM PHILLIPS MD DERMATOPATHOLOGIST LLC
Entity Type:Organization
Organization Name:DERMATOPATHOLOGY SPECIALISTS JIM PHILLIPS MD DERMATOPATHOLOGIST LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:H
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-375-0055
Mailing Address - Street 1:PO BOX 30309
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29417-0309
Mailing Address - Country:US
Mailing Address - Phone:843-554-9300
Mailing Address - Fax:843-566-8780
Practice Address - Street 1:1280 JOHNNIE DODDS BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-3287
Practice Address - Country:US
Practice Address - Phone:843-375-0055
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-21
Last Update Date:2009-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8871207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4721Medicaid
SCDG5570Medicare PIN
SC8849Medicare PIN