Provider Demographics
NPI:1457722043
Name:EASTERM DERMATOLOGY, PA
Entity type:Organization
Organization Name:EASTERM DERMATOLOGY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CAMERON
Authorized Official - Middle Name:L
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:252-752-4124
Mailing Address - Street 1:1165 CEDAR POINT BLVD
Mailing Address - Street 2:SUIE F
Mailing Address - City:CEDAR POINT
Mailing Address - State:NC
Mailing Address - Zip Code:28584-8023
Mailing Address - Country:US
Mailing Address - Phone:252-764-2986
Mailing Address - Fax:252-758-8954
Practice Address - Street 1:420 SPRING FOREST RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-7244
Practice Address - Country:US
Practice Address - Phone:252-752-4124
Practice Address - Fax:252-758-8954
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EASTERN DERMATOLOGY, PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-10-08
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC207ND0101X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC01498OtherBCBS
NC8901498Medicaid
NC230298Medicare PIN