Provider Demographics
NPI:1982260980
Name:SOUTH CHARLOTTE PLASTIC SURGERY, LLC
Entity Type:Organization
Organization Name:SOUTH CHARLOTTE PLASTIC SURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:DIEGIDIO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-898-8058
Mailing Address - Street 1:1721 EBENEZER RD STE 115
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732-1119
Mailing Address - Country:US
Mailing Address - Phone:843-898-8058
Mailing Address - Fax:843-405-7021
Practice Address - Street 1:1721 EBENEZER RD STE 115
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-1119
Practice Address - Country:US
Practice Address - Phone:843-898-8058
Practice Address - Fax:843-405-7021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-15
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty