1104847714 NPI number — POLLEY CLINIC OF DERMATOLOGY & DERMATOLOGIC SURGERY

Table of content: (NPI 1104847714)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104847714 NPI number — POLLEY CLINIC OF DERMATOLOGY & DERMATOLOGIC SURGERY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
POLLEY CLINIC OF DERMATOLOGY & DERMATOLOGIC SURGERY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104847714
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/04/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1806 GLENDALE DR SW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILSON
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27893-4402
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
252-243-0566
Provider Business Mailing Address Fax Number:
252-243-1347

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1806 GLENDALE DR SW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILSON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27893-4402
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
252-243-0566
Provider Business Practice Location Address Fax Number:
252-243-1347
Provider Enumeration Date:
07/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
NEWMAN
Authorized Official First Name:
KELLI
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING SPECIALIST
Authorized Official Telephone Number:
252-668-7026

Provider Taxonomy Codes

  • Taxonomy code: 207ND0900X , with the licence number:  27881 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2222414 . This is a "FIRST HEALTH" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 0296G . This is a "BCBS OF NC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 785505 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 68327 . This is a "ACCORDIA" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 7068303 . This is a "CIGNA" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 7257619 . This is a "AETNA" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 890296G , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: DE4848 . This is a "RAIL ROAD MEDICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 99494 . This is a "MEDCOST" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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