Basic Information
| Provider Information | |||||||||
| NPI: | 1316056104 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PIEDMONT PLASTIC SURGERY AND DERMATOLOGY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 959 COX RD | ||||||||
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| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280543420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048667576 | ||||||||
| FaxNumber: | 7048660106 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 N LAFAYETTE ST | ||||||||
| Address2: | |||||||||
| City: | SHELBY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281503829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7044840464 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2006 | ||||||||
| LastUpdateDate: | 03/09/2012 | ||||||||
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| AuthorizedOfficialLastName: | PEARSON | ||||||||
| AuthorizedOfficialFirstName: | LAWRENCE | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7044840464 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 0138T | 01 | NC | BCBS | OTHER | 8966460 | 05 | NC | MEDICAID |