Provider Demographics
NPI:1841344843
Name:CRYSTAL COAST DERMATOLOGY SERVICES, PA
Entity type:Organization
Organization Name:CRYSTAL COAST DERMATOLOGY SERVICES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EARL
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:GROSS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:252-808-3376
Mailing Address - Street 1:PO BOX 927
Mailing Address - Street 2:
Mailing Address - City:MOREHEAD CITY
Mailing Address - State:NC
Mailing Address - Zip Code:28557-0927
Mailing Address - Country:US
Mailing Address - Phone:252-808-3376
Mailing Address - Fax:252-808-2095
Practice Address - Street 1:3610 MEDICAL PARK COURT
Practice Address - Street 2:
Practice Address - City:MOREHEAD CITY
Practice Address - State:NC
Practice Address - Zip Code:28557
Practice Address - Country:US
Practice Address - Phone:252-808-3376
Practice Address - Fax:252-808-2095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC99-00855207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89011A5Medicaid
NC011A5OtherBLUE CROSS OF NC
NC=========OtherTRICARE
D02536Medicare UPIN