Provider Demographics
NPI:1043811128
Name:FOOTHILLS FAMILY DERMATOLOGY
Entity Type:Organization
Organization Name:FOOTHILLS FAMILY DERMATOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DERMATOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KIM
Authorized Official - Middle Name:D
Authorized Official - Last Name:EDHEGARD
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:828-475-2646
Mailing Address - Street 1:PO BOX 3583
Mailing Address - Street 2:
Mailing Address - City:MORGANTON
Mailing Address - State:NC
Mailing Address - Zip Code:28680
Mailing Address - Country:US
Mailing Address - Phone:828-475-2646
Mailing Address - Fax:
Practice Address - Street 1:109 E FLEMING DR STE 106
Practice Address - Street 2:
Practice Address - City:MORGANTON
Practice Address - State:NC
Practice Address - Zip Code:28655-3799
Practice Address - Country:US
Practice Address - Phone:828-475-2646
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-04
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1487855680Medicaid
NC1164657391Medicaid