Provider Demographics
NPI:1174604409
Name:SOUTH CHARLESTON DERMATOLOGY PLLC
Entity type:Organization
Organization Name:SOUTH CHARLESTON DERMATOLOGY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:LEIGH
Authorized Official - Last Name:ENDICOTT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:304-768-4567
Mailing Address - Street 1:4815 KANAWHA AVE SW
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-1207
Mailing Address - Country:US
Mailing Address - Phone:304-768-4567
Mailing Address - Fax:304-768-2277
Practice Address - Street 1:4815 KANAWHA AVE SW
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1207
Practice Address - Country:US
Practice Address - Phone:304-768-4567
Practice Address - Fax:304-768-2277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2097207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV9355431Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER