Provider Demographics
NPI:1356440663
Name:PIEDMONT COSMETIC SURGERY AND DERMATOLOGY CENTER, PA
Entity Type:Organization
Organization Name:PIEDMONT COSMETIC SURGERY AND DERMATOLOGY CENTER, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE/BILLING
Authorized Official - Prefix:MRS
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:A
Authorized Official - Last Name:SHANDRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-760-4004
Mailing Address - Street 1:765 HIGHLAND OAKS DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-7101
Mailing Address - Country:US
Mailing Address - Phone:336-760-4004
Mailing Address - Fax:336-760-6632
Practice Address - Street 1:765 HIGHLAND OAKS DR
Practice Address - Street 2:SUITE 100
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-7101
Practice Address - Country:US
Practice Address - Phone:336-760-4004
Practice Address - Fax:336-760-6632
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2010-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC400362174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890238HMedicaid
NC1616Medicare ID - Type Unspecified