Provider Demographics
NPI:1215223326
Name:CENTILLI, MICHAEL ROBERT (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ROBERT
Last Name:CENTILLI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:199 VILLAGE CENTER BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579-3589
Mailing Address - Country:US
Mailing Address - Phone:843-738-0500
Mailing Address - Fax:843-738-0505
Practice Address - Street 1:199 VILLAGE CENTER BLVD STE 200
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29579-3589
Practice Address - Country:US
Practice Address - Phone:843-738-0500
Practice Address - Fax:437-380-5058
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-27
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC52108207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty