Provider Demographics
NPI:1376969428
Name:SEASIDE DERMATOLOGY PA
Entity Type:Organization
Organization Name:SEASIDE DERMATOLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VIENNA
Authorized Official - Middle Name:L
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:843-651-4600
Mailing Address - Street 1:PO BOX 691
Mailing Address - Street 2:
Mailing Address - City:MURRELS INLET
Mailing Address - State:SC
Mailing Address - Zip Code:29576
Mailing Address - Country:US
Mailing Address - Phone:843-651-4600
Mailing Address - Fax:
Practice Address - Street 1:4017 HIGHWAY 17
Practice Address - Street 2:SUITE 200
Practice Address - City:MURRELLS INLET
Practice Address - State:SC
Practice Address - Zip Code:29576-5032
Practice Address - Country:US
Practice Address - Phone:843-651-4600
Practice Address - Fax:843-651-4601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-13
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC36498207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty