Provider Demographics
NPI:1790082873
Name:MOSES CONE AFFILIATED PHYSICIANS, INC.
Entity Type:Organization
Organization Name:MOSES CONE AFFILIATED PHYSICIANS, INC.
Other - Org Name:CAROLINA DERMATOLOGY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO/TREASURER
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:KNIGHT
Authorized Official - Last Name:BOGGS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-832-8005
Mailing Address - Street 1:PO BOX 1689
Mailing Address - Street 2:
Mailing Address - City:ETOWAH
Mailing Address - State:NC
Mailing Address - Zip Code:28729-1689
Mailing Address - Country:US
Mailing Address - Phone:828-891-5524
Mailing Address - Fax:828-891-4069
Practice Address - Street 1:1900 ASHWOOD CT
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27455-3005
Practice Address - Country:US
Practice Address - Phone:336-282-1414
Practice Address - Fax:336-282-1515
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE MOSES H. CONE MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-02-25
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5916856Medicaid
NC2347353HMedicare PIN