Provider Demographics
NPI:1023216033
Name:HILLCREST DERMATOLOGY CENTER
Entity Type:Organization
Organization Name:HILLCREST DERMATOLOGY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:GREGG
Authorized Official - Middle Name:J
Authorized Official - Last Name:COLLE MD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-535-0909
Mailing Address - Street 1:1719 VILLAGEPARK DR
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29118-2475
Mailing Address - Country:US
Mailing Address - Phone:803-535-0909
Mailing Address - Fax:
Practice Address - Street 1:1719 VILLAGEPARK DR
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29118-2475
Practice Address - Country:US
Practice Address - Phone:803-535-0909
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-11
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP1266Medicaid
SCGP1266Medicaid