Provider Demographics
NPI:1518929694
Name:DERMATOLOGY CLINIC, PA
Entity Type:Organization
Organization Name:DERMATOLOGY CLINIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:STURTZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:864-225-1656
Mailing Address - Street 1:1114 CORNELIA RD
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29621-3317
Mailing Address - Country:US
Mailing Address - Phone:864-225-1656
Mailing Address - Fax:864-225-1658
Practice Address - Street 1:1114 CORNELIA RD
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-3317
Practice Address - Country:US
Practice Address - Phone:864-225-1656
Practice Address - Fax:864-225-1658
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC11493174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC114931Medicaid
SC114931Medicaid
SC1546Medicare ID - Type Unspecified