Provider Demographics
NPI:1518278902
Name:DERMATOLOGY CENTER OF HICKORY, PA
Entity Type:Organization
Organization Name:DERMATOLOGY CENTER OF HICKORY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:PRUITT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:828-328-3500
Mailing Address - Street 1:245 11TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:HICKORY
Mailing Address - State:NC
Mailing Address - Zip Code:28601-3885
Mailing Address - Country:US
Mailing Address - Phone:828-328-3500
Mailing Address - Fax:828-328-8777
Practice Address - Street 1:245 11TH AVE NE
Practice Address - Street 2:
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28601-3885
Practice Address - Country:US
Practice Address - Phone:828-328-3500
Practice Address - Fax:828-328-8777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-30
Last Update Date:2011-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC69390OtherBLUE CROSS BLUE SHIELD OF NORTH CAROLINA
NC070015170OtherRR MEDICARE
NCC86072Medicare UPIN
NC69390OtherBLUE CROSS BLUE SHIELD OF NORTH CAROLINA