Provider Demographics
NPI:1821205097
Name:BEAUFORT DERMATOLOGY PC
Entity Type:Organization
Organization Name:BEAUFORT DERMATOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:C
Authorized Official - Last Name:BREWER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-524-5550
Mailing Address - Street 1:1096 RIBAUT ROAD
Mailing Address - Street 2:
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29902
Mailing Address - Country:US
Mailing Address - Phone:843-524-5550
Mailing Address - Fax:842-524-6798
Practice Address - Street 1:1096 RIBAUT ROAD
Practice Address - Street 2:
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29902
Practice Address - Country:US
Practice Address - Phone:843-524-5550
Practice Address - Fax:842-524-6798
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC17632207N00000X
SC17636207NP0225X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric DermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC6P1193Medicaid
E22193Medicare UPIN
SC7269Medicare ID - Type Unspecified