Provider Demographics
NPI:1770509358
Name:LOWER CAPE FEAR DERMATOLOGY CLINIC, P.A.
Entity Type:Organization
Organization Name:LOWER CAPE FEAR DERMATOLOGY CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARYLOU
Authorized Official - Middle Name:
Authorized Official - Last Name:COURREGE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-452-0400
Mailing Address - Street 1:3904 OLEANDER DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-6717
Mailing Address - Country:US
Mailing Address - Phone:910-452-0400
Mailing Address - Fax:910-452-0355
Practice Address - Street 1:3904 OLEANDER DR
Practice Address - Street 2:SUITE 102
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-6717
Practice Address - Country:US
Practice Address - Phone:910-452-0400
Practice Address - Fax:910-452-0355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2009-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103912174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2309918Medicare ID - Type Unspecified
NCD33065Medicare UPIN