Provider Demographics
NPI:1326101262
Name:NORTH CAROLINA CENTER FOR DERMATOLOGY PA
Entity Type:Organization
Organization Name:NORTH CAROLINA CENTER FOR DERMATOLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:WELLINGTON
Authorized Official - Last Name:SCALES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:919-484-9551
Mailing Address - Street 1:6216 FAYETTEVILLE RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27713-6287
Mailing Address - Country:US
Mailing Address - Phone:919-484-9551
Mailing Address - Fax:919-484-0667
Practice Address - Street 1:6216 FAYETTEVILLE RD
Practice Address - Street 2:SUITE 102
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27713-6287
Practice Address - Country:US
Practice Address - Phone:919-484-9551
Practice Address - Fax:919-484-0667
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2014-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9400629207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC012N1OtherBLUE CROSS BLUE SHIELD
NC5905605Medicaid
NC5905605Medicaid
NC012N1OtherBLUE CROSS BLUE SHIELD