1568415586 NPI number — SOUTHERN DERMATOLOGY, P.A.

Table of content: (NPI 1568415586)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568415586 NPI number — SOUTHERN DERMATOLOGY, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN DERMATOLOGY, P.A.
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:
1568415586
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/14/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1306 CONCOURSE DR STE 201
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LINTHICUM HEIGHTS
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21090-1033
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4201 LAKE BOONE TRL
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
RALEIGH
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27607-7511
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-782-2152
Provider Business Practice Location Address Fax Number:
919-782-7929
Provider Enumeration Date:
05/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PETERMAN
Authorized Official First Name:
ANGELA
Authorized Official Middle Name:
RUTH
Authorized Official Title or Position:
MD
Authorized Official Telephone Number:
443-351-3376

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  9900389 , 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)





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