Provider Demographics
NPI:1033160213
Name:GRAND STRAND DERMATOLOGY
Entity Type:Organization
Organization Name:GRAND STRAND DERMATOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-215-1100
Mailing Address - Street 1:9400 HIGHWAY 17 BYP
Mailing Address - Street 2:
Mailing Address - City:MURRELLS INLET
Mailing Address - State:SC
Mailing Address - Zip Code:29576-9300
Mailing Address - Country:US
Mailing Address - Phone:843-215-1100
Mailing Address - Fax:843-215-1211
Practice Address - Street 1:7410 HIGHWAY 707
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29588-7304
Practice Address - Country:US
Practice Address - Phone:843-215-1100
Practice Address - Fax:843-215-1211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-13
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC17893207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC178952Medicaid
SCGP0495Medicaid
SC178952Medicaid