Provider Demographics
NPI:1639195126
Name:DERMATOLOGY CARE OF CHARLOTTE, PA
Entity Type:Organization
Organization Name:DERMATOLOGY CARE OF CHARLOTTE, PA
Other - Org Name:DERMATOLOGY SPECIALISTS OF CHARLOTTE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:L
Authorized Official - Last Name:SEWARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-821-0615
Mailing Address - Street 1:15830 BALLANTYNE MEDICAL PL STE 100
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-0762
Mailing Address - Country:US
Mailing Address - Phone:704-341-0090
Mailing Address - Fax:704-341-0092
Practice Address - Street 1:15830 BALLANTYNE MEDICAL PL STE 100
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-0762
Practice Address - Country:US
Practice Address - Phone:704-341-0090
Practice Address - Fax:704-341-0092
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9800340207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCG84579Medicare UPIN
2260079Medicare ID - Type Unspecified