Provider Demographics
NPI:1649492232
Name:MOUNTAINVIEW SKIN CARE PC
Entity type:Organization
Organization Name:MOUNTAINVIEW SKIN CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:WORTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:336-893-8423
Mailing Address - Street 1:127 S POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27101-3755
Mailing Address - Country:US
Mailing Address - Phone:336-893-8423
Mailing Address - Fax:336-893-8426
Practice Address - Street 1:4680 BROWNSBORO RD B
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-3428
Practice Address - Country:US
Practice Address - Phone:336-893-8423
Practice Address - Fax:336-893-8426
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2017-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC126743261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8989261Medicaid
89261OtherBCBS NC
NC2346511OtherMEDICARE PTAN
DF5077OtherRAILROAD MEDICARE
DF5077Medicare PIN