Provider Demographics
NPI:1760043046
Name:SKIN IN THE GAME, PLLC
Entity type:Organization
Organization Name:SKIN IN THE GAME, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:HOLLY
Authorized Official - Middle Name:
Authorized Official - Last Name:HARLAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:228-864-3300
Mailing Address - Street 1:PO BOX 6625
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39506-6625
Mailing Address - Country:US
Mailing Address - Phone:228-864-3300
Mailing Address - Fax:228-864-3333
Practice Address - Street 1:6510 HIGHWAY 90
Practice Address - Street 2:
Practice Address - City:GAUTIER
Practice Address - State:MS
Practice Address - Zip Code:39553-5015
Practice Address - Country:US
Practice Address - Phone:228-864-3300
Practice Address - Fax:228-864-3333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-26
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS909605OtherMEDICARE
MS09474302Medicaid