Provider Demographics
NPI:1982783270
Name:DERMATOLOGY SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:DERMATOLOGY SURGERY CENTER, LLC
Other - Org Name:LASER & SKIN SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:A
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:BUNDY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-689-9200
Mailing Address - Street 1:15 HOSPITAL CENTER BLVD
Mailing Address - Street 2:STE 2
Mailing Address - City:HILTON HEAD
Mailing Address - State:SC
Mailing Address - Zip Code:29926
Mailing Address - Country:US
Mailing Address - Phone:843-689-9200
Mailing Address - Fax:843-689-9201
Practice Address - Street 1:15 HOSPITAL CENTER BLVD
Practice Address - Street 2:STE 2
Practice Address - City:HILTON HEAD
Practice Address - State:SC
Practice Address - Zip Code:29926
Practice Address - Country:US
Practice Address - Phone:843-689-9200
Practice Address - Fax:843-689-9201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC=========OtherEIN
SCQ328460001Medicare PIN
SC=========OtherEIN