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MYRTLE BEACH DERMATOLOGY
Complete NPI Record 1285683003
Dermatology in Myrtle Beach, SC

NPI Status: Active since May 09, 2006

Contact Information

1275 21ST AVE N BLDG 2
MYRTLE BEACH, SC
ZIP 29577
Phone: (843) 449-9140
Fax: (843) 497-5110

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Table of Contents

  1. NPI
  2. Entity Type Code
  3. Employer Identification Number EIN
  4. Provider Organization Name Legal Business Name
  5. Provider First Line Business Mailing Address
  6. Provider Business Mailing Address City Name
  7. Provider Business Mailing Address State Name
  8. Provider Business Mailing Address Postal Code
  9. Provider Business Mailing Address Country Code If outside U S
  10. Provider Business Mailing Address Telephone Number
  11. Provider Business Mailing Address Fax Number
  12. Provider First Line Business Practice Location Address
  13. Provider Business Practice Location Address City Name
  14. Provider Business Practice Location Address State Name
  15. Provider Business Practice Location Address Postal Code
  16. Provider Business Practice Location Address Country Code If outside U S
  17. Provider Business Practice Location Address Telephone Number
  18. Provider Business Practice Location Address Fax Number
  19. Provider Enumeration Date
  20. Last Update Date
  21. Authorized Official Last Name
  22. Authorized Official First Name
  23. Authorized Official Middle Name
  24. Authorized Official Title or Position
  25. Authorized Official Telephone Number
  26. Healthcare Provider Taxonomy Code 1
  27. Provider License Number 1
  28. Provider License Number State Code 1
  29. Healthcare Provider Primary Taxonomy Switch 1
  30. Is Organization Subpart
  31. Authorized Official Name Prefix Text
  32. Authorized Official Name Suffix Text
  33. Authorized Official Credential Text
  34. Healthcare Provider Taxonomy Group 1
  35. NPI Certification Date

Complete NPI Dataset

This page represents the complete record for NPI 1285683003. You can access the complete dataset, including a full list of field names, along with their values, and definitions as recorded by the NPI registry. Each field in the NPI record is explained, highlighting its significance and the possible values it can hold.

NPI: 1285683003
The State code in the location of the provider being identified.
Entity Type Code: 2
The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available.
Employer Identification Number EIN: UNAVAIL
The Employer Identification Number (EIN), assigned by the IRS, of the provider being identified.
The name of the organization provider. If the provider is an organization, this is the legal business name.
Provider First Line Business Mailing Address: 1275 21ST AVE N BLDG 2
The first line mailing address of the provider being identified. This data element may contain the same information as ‘‘Provider first line location address’’.
Provider Business Mailing Address City Name: MYRTLE BEACH
The city name in the mailing address of the provider being identified.
Provider Business Mailing Address State Name: SC
The State or Province name in the mailing address of the provider being identified. This data element may contain the same information as ‘‘Provider location address State name’’.
Provider Business Mailing Address Postal Code: 295777514
Code designating the provider type, classification, and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1.
Provider Business Mailing Address Country Code If outside U S : US
The license number issued to the provider being identified. The NPS can accommodate multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with ‘‘provider taxonomy code’’.
Provider Business Mailing Address Telephone Number: 8434499140
The telephone number associated with mailing address of the provider being identified. This data element may contain the same information as ‘‘Provider location address telephone number’’.
Provider Business Mailing Address Fax Number: 8434975110
The fax number associated with the mailing address of the provider being identified. This data element may contain the same information as ‘‘Provider location address fax number’’.
Provider First Line Business Practice Location Address: 1275 21ST AVE N BLDG 2
The first line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box.
Provider Business Practice Location Address City Name: MYRTLE BEACH
The city name in the location address of the provider being identified.
Provider Business Practice Location Address State Name: SC
The State code in the location of the provider being identified.
Provider Business Practice Location Address Postal Code: 295777514
The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available.
Provider Business Practice Location Address Country Code If outside U S : US
The country code in the location address of the provider being identified.
Provider Business Practice Location Address Telephone Number: 8434499140
The telephone number associated with the location address of the provider being identified.
Provider Business Practice Location Address Fax Number: 8434975110
The fax number associated with the location address of the provider being identified.
Provider Enumeration Date: 5/9/2006
The date the provider was assigned a unique identifier (assigned an NPI).
Last Update Date: 8/20/2024
The date that a record was last updated or changed.
Authorized Official Last Name: HUSSEY
The last name of the person authorized to submit the NPI application or to change NPS data for a health care provider.
Authorized Official First Name: RICHARD
The first name of the authorized official.
Authorized Official Middle Name: HENRY
The middle name of the authorized official.
Authorized Official Title or Position: PARTNER
The title or position of the authorized official.
Authorized Official Telephone Number: 8434499410
The 10-position telephone number of the authorized official.
Healthcare Provider Taxonomy Code 1: 207N00000X
Code designating the provider type, classification, and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1.
Provider License Number 1: 19296
The license number issued to the provider being identified. The NPS can accommodate multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with ‘‘provider taxonomy code’’.
Provider License Number State Code 1: SC
The code representing the State that issued the license to the provider being identified. This field can accommodate multiple States. It is associated with ‘‘provider license number.
Healthcare Provider Primary Taxonomy Switch 1: Y
Is Organization Subpart: N
Authorized Official Name Prefix Text: DR.
Authorized Official Name Suffix Text: III
Authorized Official Credential Text: M.D.
Healthcare Provider Taxonomy Group 1: 193400000X SINGLE SPECIALTY GROUP
NPI Certification Date: 8/20/2024