Provider Demographics
NPI:1417913260
Name:BOONE DERMATOLOGY CLINIC
Entity Type:Organization
Organization Name:BOONE DERMATOLOGY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:J
Authorized Official - Last Name:STANLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:828-264-4553
Mailing Address - Street 1:169 BIRCH ST
Mailing Address - Street 2:
Mailing Address - City:BOONE
Mailing Address - State:NC
Mailing Address - Zip Code:28607-5069
Mailing Address - Country:US
Mailing Address - Phone:828-264-4553
Mailing Address - Fax:828-262-3649
Practice Address - Street 1:169 BIRCH ST
Practice Address - Street 2:
Practice Address - City:BOONE
Practice Address - State:NC
Practice Address - Zip Code:28607-5069
Practice Address - Country:US
Practice Address - Phone:828-264-4553
Practice Address - Fax:828-262-3649
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-21
Last Update Date:2015-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC18060207N00000X
NC25707207N00000X
NC200000665207N00000X
NC200500862207N00000X
NC39986207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC01404OtherBLUE CROSS BLUE SHIELD
NC8901404Medicaid
NC0800Medicare PIN
NC8901404Medicaid