Provider Demographics
NPI:1639398480
Name:ANDERSON SKIN AND CANCER CLINIC
Entity Type:Organization
Organization Name:ANDERSON SKIN AND CANCER CLINIC
Other - Org Name:DERMATOPATHOLOGY CONSULTATION SERVICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:JOHNSON
Authorized Official - Last Name:QUARTERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-224-7577
Mailing Address - Street 1:2022 CARDINAL CIR
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29621-1504
Mailing Address - Country:US
Mailing Address - Phone:864-224-7577
Mailing Address - Fax:864-225-5165
Practice Address - Street 1:2022 CARDINAL CIR
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-1504
Practice Address - Country:US
Practice Address - Phone:864-224-7577
Practice Address - Fax:864-225-5165
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC16908207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC2961Medicaid
SC2329OtherMEDICARE ID
SC3937PAMedicaid
SCNP2759Medicaid
SCSC98802329OtherMC PTAN
SCTL7847Medicaid
SC404271Medicaid
SCAA5766OtherMC UPIN
SCPA4496Medicaid
SCTL7847Medicaid
F62908Medicare UPIN
B916312329Medicare ID - Type Unspecified