1881864411 NPI number — RALEIGH SKIN SURGERY CENTER

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881864411 NPI number — RALEIGH SKIN SURGERY CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RALEIGH SKIN SURGERY CENTER
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:
1881864411
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/19/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3811 ED DRIVE
Provider Second Line Business Mailing Address:
SUITE 110
Provider Business Mailing Address City Name:
RALEIGH
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27612-8106
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-390-0200
Provider Business Mailing Address Fax Number:
919-390-0219

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3811 ED DR.
Provider Second Line Business Practice Location Address:
110
Provider Business Practice Location Address City Name:
RALEIGH
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27612-8106
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-390-0200
Provider Business Practice Location Address Fax Number:
919-390-0219
Provider Enumeration Date:
03/11/2008

Additional Information

Authorized Official

Authorized Official Last Name:
HOUSMAN
Authorized Official First Name:
TAMARA
Authorized Official Middle Name:
S
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
919-390-0210

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207ND0101X , with the licence number: 200001428 , registered in the state of NC ; 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: "Y" .

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

  • Identifier: 2021987A . This is a "MEDICARE PTAN" identifier . This identifiers is of the category "OTHER".




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