Provider Demographics
NPI:1487641429
Name:ADVANCED DERMATOLOGY CENTER, PA
Entity Type:Organization
Organization Name:ADVANCED DERMATOLOGY CENTER, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STANLEY
Authorized Official - Middle Name:D
Authorized Official - Last Name:HOFFMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-895-6775
Mailing Address - Street 1:9604 HOLLY POINT DR
Mailing Address - Street 2:
Mailing Address - City:HUNTERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28078-4913
Mailing Address - Country:US
Mailing Address - Phone:704-895-6775
Mailing Address - Fax:704-895-6765
Practice Address - Street 1:9604 HOLLY POINT DR
Practice Address - Street 2:
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078-4913
Practice Address - Country:US
Practice Address - Phone:704-895-6775
Practice Address - Fax:704-895-6765
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-04
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200000825207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC015UGOtherBCBS
NC015UGOtherBCBS