Provider Demographics
NPI:1609927623
Name:NEW AGE DERMATOLOGY CENTER PA
Entity Type:Organization
Organization Name:NEW AGE DERMATOLOGY CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICSUNICA ELVIRA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHIRITESCU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:919-624-2802
Mailing Address - Street 1:1091 PEMBERTON HILL RD STE 201
Mailing Address - Street 2:
Mailing Address - City:APEX
Mailing Address - State:NC
Mailing Address - Zip Code:27502-4269
Mailing Address - Country:US
Mailing Address - Phone:919-367-3625
Mailing Address - Fax:919-367-3608
Practice Address - Street 1:1091 PEMBERTON HILL RD STE 201
Practice Address - Street 2:
Practice Address - City:APEX
Practice Address - State:NC
Practice Address - Zip Code:27502-4269
Practice Address - Country:US
Practice Address - Phone:919-367-3625
Practice Address - Fax:919-367-3608
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2014-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2000-00747207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC129EROtherBLUE CROSS BLUE SHEILD
NC89129ERMedicaid
NCH53515Medicare UPIN
NC129EROtherBLUE CROSS BLUE SHEILD