Provider Demographics
NPI:1619194404
Name:MEDICAL & SURGICAL DERMATOLOGY, LLC
Entity Type:Organization
Organization Name:MEDICAL & SURGICAL DERMATOLOGY, LLC
Other - Org Name:WESTGATE DERMATOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:J
Authorized Official - Last Name:NEIDENBACH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:828-894-2473
Mailing Address - Street 1:52 HOSPITAL DR STE 3A
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:NC
Mailing Address - Zip Code:28722-8516
Mailing Address - Country:US
Mailing Address - Phone:828-894-2473
Mailing Address - Fax:828-894-2390
Practice Address - Street 1:52 HOSPITAL DR STE 3A
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:NC
Practice Address - Zip Code:28722-8516
Practice Address - Country:US
Practice Address - Phone:828-859-6697
Practice Address - Fax:828-894-2390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC66555207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC9501356OtherMEDICAL LICENSE
NC2336482OtherMEDICARE PTAN
SCMMM.16384MDOtherMEDICAL LICENSE