Provider Demographics
NPI:1932595816
Name:MAGNOLIA DERMATOLOGY, LLC
Entity Type:Organization
Organization Name:MAGNOLIA DERMATOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:N
Authorized Official - Last Name:MYERS
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:843-769-2100
Mailing Address - Street 1:48 FOLLY ROAD BLVD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-7507
Mailing Address - Country:US
Mailing Address - Phone:843-769-2100
Mailing Address - Fax:
Practice Address - Street 1:48 FOLLY ROAD BLVD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-7507
Practice Address - Country:US
Practice Address - Phone:843-769-2100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-08
Last Update Date:2015-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCMD31744207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCMD31744OtherPROFESSIONAL LICENSE