Provider Demographics
NPI:1982669131
Name:CAROLINA MOUNTAIN DERMATOLOGY, PA
Entity Type:Organization
Organization Name:CAROLINA MOUNTAIN DERMATOLOGY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:COGBURN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:828-684-0703
Mailing Address - Street 1:78 LONG SHOALS RD
Mailing Address - Street 2:
Mailing Address - City:ARDEN
Mailing Address - State:NC
Mailing Address - Zip Code:28704-7782
Mailing Address - Country:US
Mailing Address - Phone:828-684-0703
Mailing Address - Fax:828-684-5344
Practice Address - Street 1:78 LONG SHOALS RD
Practice Address - Street 2:
Practice Address - City:ARDEN
Practice Address - State:NC
Practice Address - Zip Code:28704-7782
Practice Address - Country:US
Practice Address - Phone:828-684-0703
Practice Address - Fax:828-684-5344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC40729207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC=========OtherFEDERAL TAX I.D.