Provider Demographics
NPI:1073549150
Name:WINSTON SALEM DERMATOLOGY & SURGERY
Entity Type:Organization
Organization Name:WINSTON SALEM DERMATOLOGY & SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:YUENGEL-BIENENFELD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:336-774-8636
Mailing Address - Street 1:1400 WESTGATE CENTER DR., STE. 200
Mailing Address - Street 2:
Mailing Address - City:WINSTON-SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103
Mailing Address - Country:US
Mailing Address - Phone:336-774-8636
Mailing Address - Fax:336-774-0265
Practice Address - Street 1:1400 WESTGATE CENTER DR., STE. 200
Practice Address - Street 2:
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103
Practice Address - Country:US
Practice Address - Phone:336-774-8636
Practice Address - Fax:336-774-0265
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-23
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9601111207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC017G0OtherBCBS OF NC
NC2349839Medicare ID - Type Unspecified