Provider Demographics
NPI:1104847714
Name:POLLEY CLINIC OF DERMATOLOGY & DERMATOLOGIC SURGERY
Entity Type:Organization
Organization Name:POLLEY CLINIC OF DERMATOLOGY & DERMATOLOGIC SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:KELLI
Authorized Official - Middle Name:
Authorized Official - Last Name:NEWMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-668-7026
Mailing Address - Street 1:1806 GLENDALE DR SW
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:NC
Mailing Address - Zip Code:27893-4402
Mailing Address - Country:US
Mailing Address - Phone:252-243-0566
Mailing Address - Fax:252-243-1347
Practice Address - Street 1:1806 GLENDALE DR SW
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893-4402
Practice Address - Country:US
Practice Address - Phone:252-243-0566
Practice Address - Fax:252-243-1347
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC27881207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2222414OtherFIRST HEALTH
NC0296GOtherBCBS OF NC
NC785505OtherUNITED HEALTH CARE
NC68327OtherACCORDIA
NC7068303OtherCIGNA
NC7257619OtherAETNA
NC890296GMedicaid
NCDE4848OtherRAIL ROAD MEDICARE
NC99494OtherMEDCOST
NC890296GMedicaid