1144282930 NPI number — CAROLINA DERMATOLOGY, LLC

Table of content: (NPI 1144282930)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144282930 NPI number — CAROLINA DERMATOLOGY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CAROLINA DERMATOLOGY, LLC
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:
1144282930
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/01/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10502 PARK RD
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28210-8479
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-542-1366
Provider Business Mailing Address Fax Number:
704-542-1063

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10502 PARK RD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28210-8479
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-542-1366
Provider Business Practice Location Address Fax Number:
704-542-1063
Provider Enumeration Date:
04/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
COOLEY
Authorized Official First Name:
GERALD
Authorized Official Middle Name:
EARL
Authorized Official Title or Position:
PRESIDENT/OWNER
Authorized Official Telephone Number:
704-542-1366

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0212C . This is a "BCBS OF NC GROUP #" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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