Provider Demographics
NPI:1447911938
Name:ADVANCED DERMATOLOGY OF SC PC
Entity type:Organization
Organization Name:ADVANCED DERMATOLOGY OF SC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR PROVIDER ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:DECLUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-917-7293
Mailing Address - Street 1:151 SOUTHHALL LN STE 300
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-7172
Mailing Address - Country:US
Mailing Address - Phone:079-177-2934
Mailing Address - Fax:407-650-3455
Practice Address - Street 1:1700 FIRST BAXTER XING STE 101
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29708-8950
Practice Address - Country:US
Practice Address - Phone:803-802-3376
Practice Address - Fax:803-802-3329
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ADVANCED DERMATOLOGY OF SC PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-01-06
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty