Provider Demographics
NPI:1912002460
Name:PINEHURST DERMATOLOGY PA
Entity Type:Organization
Organization Name:PINEHURST DERMATOLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:VICKIE
Authorized Official - Middle Name:F
Authorized Official - Last Name:MILLENBAUGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-295-8748
Mailing Address - Street 1:120 BRAEMAR CT
Mailing Address - Street 2:
Mailing Address - City:PINEHURST
Mailing Address - State:NC
Mailing Address - Zip Code:28374-8747
Mailing Address - Country:US
Mailing Address - Phone:910-295-5567
Mailing Address - Fax:910-295-3315
Practice Address - Street 1:120 BRAEMAR CT
Practice Address - Street 2:
Practice Address - City:PINEHURST
Practice Address - State:NC
Practice Address - Zip Code:28374-8747
Practice Address - Country:US
Practice Address - Phone:910-295-5567
Practice Address - Fax:910-295-3315
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC02423OtherBLUE CROSS
NC8902423Medicaid
NC230242Medicare ID - Type Unspecified