Provider Demographics
NPI:1497940944
Name:MID-CHARLOTTE DERMATOLOGY AND RESEARCH PLLC
Entity Type:Organization
Organization Name:MID-CHARLOTTE DERMATOLOGY AND RESEARCH PLLC
Other - Org Name:SOUTHEAST VULVAR CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:IRENE
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-367-9777
Mailing Address - Street 1:6406 CARMEL RD STE 309
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28226-8267
Mailing Address - Country:US
Mailing Address - Phone:704-367-9777
Mailing Address - Fax:704-367-0504
Practice Address - Street 1:6406 CARMEL RD STE 309
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28226-8267
Practice Address - Country:US
Practice Address - Phone:704-367-9777
Practice Address - Fax:704-367-0504
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-07
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC23521207N00000X, 207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5922883Medicaid
NC2328755Medicare PIN
NC5922883Medicaid