Provider Demographics
NPI:1316943145
Name:CENTRAL CAROLINA DERMATOLOGY CLINIC, INC
Entity type:Organization
Organization Name:CENTRAL CAROLINA DERMATOLOGY CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KRISTINE
Authorized Official - Middle Name:N
Authorized Official - Last Name:KEARNS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-934-5070
Mailing Address - Street 1:4010 MENDENHALL OAKS PKWY
Mailing Address - Street 2:
Mailing Address - City:HIGH POINT
Mailing Address - State:NC
Mailing Address - Zip Code:27265-8076
Mailing Address - Country:US
Mailing Address - Phone:336-887-3195
Mailing Address - Fax:336-887-3194
Practice Address - Street 1:4010 MENDENHALL OAKS PKWY
Practice Address - Street 2:
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27265-8076
Practice Address - Country:US
Practice Address - Phone:336-887-3195
Practice Address - Fax:336-887-3194
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-27
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC34D0238143207NI0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NI0002XAllopathic & Osteopathic PhysiciansDermatologyClinical & Laboratory Dermatological ImmunologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCCD4358OtherRAILROAD MEDICARE
NC230129OtherMEDICARE GROUP NUMBER
NC8901788Medicaid