Provider Demographics
NPI:1760713671
Name:EASTERN DERMATOLOGY & PATHOLOGY, PA
Entity Type:Organization
Organization Name:EASTERN DERMATOLOGY & PATHOLOGY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CAMERON
Authorized Official - Middle Name:LANGLEY
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:252-752-4124
Mailing Address - Street 1:420 SPRING FOREST RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-7244
Mailing Address - Country:US
Mailing Address - Phone:252-752-4124
Mailing Address - Fax:252-752-6106
Practice Address - Street 1:1314 HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:NC
Practice Address - Zip Code:27889-3424
Practice Address - Country:US
Practice Address - Phone:252-752-4124
Practice Address - Fax:252-752-6106
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EASTERN DERMATOLOGY & PATHOLOGY, PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-01-18
Last Update Date:2011-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC01498OtherBCBSNC
NC230298OtherMEDICARE
NC8901498Medicaid