Provider Demographics
NPI:1366539041
Name:RUTHERFORD DERMATOLOGY, PA
Entity type:Organization
Organization Name:RUTHERFORD DERMATOLOGY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:CAROL
Authorized Official - Last Name:SELSOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:828-288-1204
Mailing Address - Street 1:PO BOX 1689
Mailing Address - Street 2:
Mailing Address - City:ETOWAH
Mailing Address - State:NC
Mailing Address - Zip Code:28729-1689
Mailing Address - Country:US
Mailing Address - Phone:828-233-1354
Mailing Address - Fax:828-233-1354
Practice Address - Street 1:651 WITHROW RD
Practice Address - Street 2:
Practice Address - City:FOREST CITY
Practice Address - State:NC
Practice Address - Zip Code:28043-9695
Practice Address - Country:US
Practice Address - Phone:828-288-1204
Practice Address - Fax:828-288-1205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89011RPMedicaid