1710352992 NPI number — DERMONE PLASTIC SURGERY ASSOCIATES OF NORTH CAROLINA, PA

Table of content: (NPI 1710352992)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710352992 NPI number — DERMONE PLASTIC SURGERY ASSOCIATES OF NORTH CAROLINA, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DERMONE PLASTIC SURGERY ASSOCIATES OF NORTH CAROLINA, 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:
1710352992
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/14/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 BARR HARBOR DRIVE, SUITE 200
Provider Second Line Business Mailing Address:
FOUR TOWER BRIDGE
Provider Business Mailing Address City Name:
WEST CONSHOHOCKEN
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19428
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
848-240-2812
Provider Business Mailing Address Fax Number:
732-731-6135

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6752 ROCK SPRING RD
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
WILMINGTON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28405-3179
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-762-1070
Provider Business Practice Location Address Fax Number:
732-731-6735
Provider Enumeration Date:
12/14/2015

Additional Information

Authorized Official

Authorized Official Last Name:
BLANKS
Authorized Official First Name:
DEIDRA
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
910-840-3093

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207ND0101X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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