Provider Demographics
NPI:1639202294
Name:CAROLINA DERMATOLOGY CLINIC, PA
Entity Type:Organization
Organization Name:CAROLINA DERMATOLOGY CLINIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:A
Authorized Official - Last Name:KOTZ
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:843-766-9868
Mailing Address - Street 1:933 SAINT ANDREWS BLVD.
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407
Mailing Address - Country:US
Mailing Address - Phone:843-766-9868
Mailing Address - Fax:843-571-4925
Practice Address - Street 1:933 SAINT ANDREWS BLVD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407
Practice Address - Country:US
Practice Address - Phone:843-766-9868
Practice Address - Fax:843-571-4925
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC24039174400000X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC240395Medicaid
SCGROUPGP4945Medicaid
SCAA07608162Medicare PIN
SCI24579Medicare UPIN