Provider Demographics
NPI:1790340750
Name:ANDERSON DERMATOLOGY AND SKIN SURGERY CENTER
Entity Type:Organization
Organization Name:ANDERSON DERMATOLOGY AND SKIN SURGERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:GREER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-716-0063
Mailing Address - Street 1:1501 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29621-4734
Mailing Address - Country:US
Mailing Address - Phone:864-716-0063
Mailing Address - Fax:864-716-0073
Practice Address - Street 1:112 JOHN ST STE 105
Practice Address - Street 2:
Practice Address - City:EASLEY
Practice Address - State:SC
Practice Address - Zip Code:29640-1405
Practice Address - Country:US
Practice Address - Phone:864-855-2052
Practice Address - Fax:864-855-2518
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ANDERSON DERMATOLOGY AND SKIN SURGERY CENTER, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-05-06
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP3575Medicaid