Provider Demographics
NPI:1265477251
Name:CHARLOTTE DERMATOLOGY PA
Entity Type:Organization
Organization Name:CHARLOTTE DERMATOLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:SLAUGHTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-927-6160
Mailing Address - Street 1:PO BOX 60800
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0800
Mailing Address - Country:US
Mailing Address - Phone:704-927-6166
Mailing Address - Fax:704-364-4845
Practice Address - Street 1:2630 E 7TH ST
Practice Address - Street 2:200
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-4318
Practice Address - Country:US
Practice Address - Phone:704-927-6166
Practice Address - Fax:704-364-4845
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-17
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0467OtherMEDICARE GROUP