Provider Demographics
NPI:1972715241
Name:EASTERN DERMATOLOGY PA
Entity Type:Organization
Organization Name:EASTERN DERMATOLOGY 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:252-758-8954
Practice Address - Street 1:222 VIRGINIA RD
Practice Address - Street 2:
Practice Address - City:EDENTON
Practice Address - State:NC
Practice Address - Zip Code:27932-9667
Practice Address - Country:US
Practice Address - Phone:252-482-5661
Practice Address - Fax:252-758-8954
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5902502Medicaid
NC01498OtherBCBS NC
NC230298Medicare ID - Type UnspecifiedGROUP NUMBER