Provider Demographics
NPI:1285683003
Name:MYRTLE BEACH DERMATOLOGY
Entity Type:Organization
Organization Name:MYRTLE BEACH DERMATOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:HENRY
Authorized Official - Last Name:HUSSEY
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:843-449-9410
Mailing Address - Street 1:4573 OLEANDER DR
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29577-5755
Mailing Address - Country:US
Mailing Address - Phone:843-449-9140
Mailing Address - Fax:843-497-5110
Practice Address - Street 1:1275 21ST AVE N BLDG 2
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-7514
Practice Address - Country:US
Practice Address - Phone:843-449-9140
Practice Address - Fax:843-497-5110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-09
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19296207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4300Medicaid
SC=========OtherBCBS AND OTHER INSURANCES
SC=========OtherBCBS AND OTHER INSURANCES