Provider Demographics
NPI:1568415586
Name:SOUTHERN DERMATOLOGY, P.A.
Entity Type:Organization
Organization Name:SOUTHERN DERMATOLOGY, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:RUTH
Authorized Official - Last Name:PETERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-351-3376
Mailing Address - Street 1:1306 CONCOURSE DR STE 201
Mailing Address - Street 2:
Mailing Address - City:LINTHICUM HEIGHTS
Mailing Address - State:MD
Mailing Address - Zip Code:21090-1033
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4201 LAKE BOONE TRL
Practice Address - Street 2:SUITE 200
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-7511
Practice Address - Country:US
Practice Address - Phone:919-782-2152
Practice Address - Fax:919-782-7929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9900389174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2329891Medicare PIN