Provider Demographics
NPI:1073946315
Name:DERMATOLOGY AND SKIN CANCER CENTER OF SOUTH CAROLINA PC
Entity Type:Organization
Organization Name:DERMATOLOGY AND SKIN CANCER CENTER OF SOUTH CAROLINA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOSPEH
Authorized Official - Middle Name:M
Authorized Official - Last Name:MASESSA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-668-4104
Mailing Address - Street 1:5046 HIGHWAY 17 BYP S
Mailing Address - Street 2:SUITE 103
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29588-4503
Mailing Address - Country:US
Mailing Address - Phone:843-688-4104
Mailing Address - Fax:201-848-8902
Practice Address - Street 1:5046 HIGHWAY 17 BYP S
Practice Address - Street 2:SUITE 103
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29588-4503
Practice Address - Country:US
Practice Address - Phone:843-668-4104
Practice Address - Fax:201-848-8902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-09
Last Update Date:2013-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCMD35615207N00000X, 207ND0101X, 207ND0900X, 207NI0002X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Single Specialty
No207NI0002XAllopathic & Osteopathic PhysiciansDermatologyClinical & Laboratory Dermatological ImmunologyGroup - Single Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty