1508976432 NPI number — KINSTON DERMATOLOGY, PA

Table of content: (NPI 1508976432)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508976432 NPI number — KINSTON DERMATOLOGY, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KINSTON DERMATOLOGY, PA
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:
1508976432
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
701 DOCTORS DR
Provider Second Line Business Mailing Address:
KINSTON CLINIC NORTH, SUITE F
Provider Business Mailing Address City Name:
KINSTON
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28501-1584
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
252-523-3289
Provider Business Mailing Address Fax Number:
252-523-1310

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
701 DOCTORS DR
Provider Second Line Business Practice Location Address:
KINSTON CLINIC NORTH, SUITE F
Provider Business Practice Location Address City Name:
KINSTON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28501-1584
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
252-523-3289
Provider Business Practice Location Address Fax Number:
252-523-1310
Provider Enumeration Date:
08/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HENSHAW
Authorized Official First Name:
DIANA
Authorized Official Middle Name:
MONROE
Authorized Official Title or Position:
SECRETARY/TREASURER
Authorized Official Telephone Number:
252-523-3289

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  84026 , 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: 0105H . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 790105H , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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