Provider Demographics
NPI:1972567634
Name:GOLDSBORO SKIN CENTER PA
Entity type:Organization
Organization Name:GOLDSBORO SKIN CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:L
Authorized Official - Last Name:JENNINGS
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:919-736-0222
Mailing Address - Street 1:2613 HOSPITAL RD
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27534-9424
Mailing Address - Country:US
Mailing Address - Phone:919-736-0222
Mailing Address - Fax:919-736-0223
Practice Address - Street 1:2613 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27534-9424
Practice Address - Country:US
Practice Address - Phone:919-736-0222
Practice Address - Fax:919-736-0223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC27212207N00000X, 207ND0900X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
Not Answered207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Multi-Specialty
Not Answered207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89012KTMedicaid
NC89012KTMedicaid
NC2325060Medicare ID - Type Unspecified