Provider Demographics
NPI:1083693857
Name:CAROLINA DERMATOLOGY GRP
Entity Type:Organization
Organization Name:CAROLINA DERMATOLOGY GRP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:G
Authorized Official - Last Name:BLASKIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:803-771-7506
Mailing Address - Street 1:1706 ST JULIANS PLACE
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204-2410
Mailing Address - Country:US
Mailing Address - Phone:803-771-7506
Mailing Address - Fax:803-771-9455
Practice Address - Street 1:1706 ST JULIANS PLACE
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-2410
Practice Address - Country:US
Practice Address - Phone:803-771-7506
Practice Address - Fax:803-771-9455
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-11
Last Update Date:2011-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC207N00000X, 207ND0101X
207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP1028Medicaid
SCH57701Medicare UPIN
SCAA13324810Medicare UPIN
SCGP1028Medicaid
SCAA70174810Medicare UPIN
SCAA08524810Medicare UPIN
SCAA42004810Medicare UPIN
SCF96824Medicare UPIN
SCH36795Medicare UPIN
SC4810Medicare PIN
SCH89943Medicare UPIN