Provider Demographics
NPI:1508189838
Name:DERMATOLOGY AND LASER CENTER OF CHARLESTON/PALMETTO STATE PHARM
Entity Type:Organization
Organization Name:DERMATOLOGY AND LASER CENTER OF CHARLESTON/PALMETTO STATE PHARM
Other - Org Name:PRIMARY RX
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:KNAPP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-408-4171
Mailing Address - Street 1:2000 SAM RITTENBERG BLVD
Mailing Address - Street 2:SUITE 3009
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-4629
Mailing Address - Country:US
Mailing Address - Phone:843-769-7633
Mailing Address - Fax:888-318-5567
Practice Address - Street 1:2093 HENRY TECKLENBURG DR
Practice Address - Street 2:SUITE 300
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-5741
Practice Address - Country:US
Practice Address - Phone:843-556-8886
Practice Address - Fax:888-318-5567
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-01
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19977207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC8276OtherMEDICARE TYPE UNSPECIFIED