Provider Demographics
NPI:1245675636
Name:SUNGATE DERMATOLOGY
Entity type:Organization
Organization Name:SUNGATE DERMATOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:FARR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-842-2020
Mailing Address - Street 1:10 WILLIAM POPE DR
Mailing Address - Street 2:SUNGATE MEDICAL CENTER, SUITE #4
Mailing Address - City:BLUFFTON
Mailing Address - State:SC
Mailing Address - Zip Code:29909-7549
Mailing Address - Country:US
Mailing Address - Phone:843-705-1513
Mailing Address - Fax:843-705-1514
Practice Address - Street 1:10 WILLIAM POPE DR
Practice Address - Street 2:SUNGATE MEDICAL CENTER, SUITE #4
Practice Address - City:BLUFFTON
Practice Address - State:SC
Practice Address - Zip Code:29909-7549
Practice Address - Country:US
Practice Address - Phone:843-705-1513
Practice Address - Fax:843-705-1514
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PALMETTO EYE SPECIALISTS PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-04-30
Last Update Date:2013-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCMD31744207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC6830OtherMEDICARE
SCCH3121OtherRAILROAD MEDICARE
SCGP2666Medicaid
SCP00764908OtherMEDICARE GROUP PTAN