1538240486 NPI number — PIEDMONT DERMATOLOGY CENTER, PC

Table of content: (NPI 1538240486)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538240486 NPI number — PIEDMONT DERMATOLOGY CENTER, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PIEDMONT DERMATOLOGY CENTER, PC
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:
1538240486
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/03/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
314 FAIRY STREET EXT
Provider Second Line Business Mailing Address:
SUITE D
Provider Business Mailing Address City Name:
MARTINSVILLE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24112-1913
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
276-666-8439
Provider Business Mailing Address Fax Number:
276-666-8440

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
314 FAIRY STREET EXT
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
MARTINSVILLE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24112-1913
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
276-666-8439
Provider Business Practice Location Address Fax Number:
276-666-8440
Provider Enumeration Date:
10/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GROSS
Authorized Official First Name:
NED
Authorized Official Middle Name:
JAY
Authorized Official Title or Position:
PRESIDENT/MEDICAL DOCTOR
Authorized Official Telephone Number:
276-666-8439

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  0101228761 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 070015390 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 9767433 . This is a "CIGNA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 285584 . This is a "ANTHEM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 89011P5 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7986163 . This is a "AETNA" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: A1547 . This is a "MEDCOST" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 0308562 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: A1547 . This is a "MEDCOST" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 011P5 . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 070015616 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 7986163 . This is a "AETNA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 9767433 . This is a "CIGNA" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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