Provider Demographics
NPI:1881864411
Name:RALEIGH SKIN SURGERY CENTER
Entity Type:Organization
Organization Name:RALEIGH SKIN SURGERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TAMARA
Authorized Official - Middle Name:S
Authorized Official - Last Name:HOUSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:919-390-0210
Mailing Address - Street 1:3811 ED DRIVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-8106
Mailing Address - Country:US
Mailing Address - Phone:919-390-0200
Mailing Address - Fax:919-390-0219
Practice Address - Street 1:3811 ED DR.
Practice Address - Street 2:110
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27612-8106
Practice Address - Country:US
Practice Address - Phone:919-390-0200
Practice Address - Fax:919-390-0219
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-11
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207N00000X, 207ND0101X
NC200001428207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
2021987AOtherMEDICARE PTAN