Provider Demographics
NPI:1710943584
Name:DEBERRY, SKYE NICOLE (MD)
Entity Type:Individual
Prefix:
First Name:SKYE
Middle Name:NICOLE
Last Name:DEBERRY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 751649
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1649
Mailing Address - Country:US
Mailing Address - Phone:843-789-1620
Mailing Address - Fax:843-724-2440
Practice Address - Street 1:1525 OLD TROLLEY RD STE H
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29485-8928
Practice Address - Country:US
Practice Address - Phone:843-212-8080
Practice Address - Fax:843-212-8077
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC22301207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC080167628OtherMEDICARE RAIL ROAD
SC223010Medicaid
SC223010Medicaid
SCH341305281Medicare PIN
SCH34130Medicare UPIN