Provider Demographics
NPI:1821048828
Name:MT PLEASANT DERMATOLOGY
Entity Type:Organization
Organization Name:MT PLEASANT DERMATOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:TONYA
Authorized Official - Middle Name:M
Authorized Official - Last Name:ROPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-936-7189
Mailing Address - Street 1:570 LONG POINT ROAD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MT. PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464
Mailing Address - Country:US
Mailing Address - Phone:843-881-0320
Mailing Address - Fax:843-881-5453
Practice Address - Street 1:570 LONG POINT ROAD
Practice Address - Street 2:SUITE 200
Practice Address - City:MT. PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464
Practice Address - Country:US
Practice Address - Phone:843-881-0320
Practice Address - Fax:843-881-5453
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC174400000X
207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC7818Medicare PIN