Basic Information
| Provider Information | |||||||||
| NPI: | 1477842573 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BEAVERS DERMATOLOGY & SKIN SURGERY, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1693 | ||||||||
| Address2: | |||||||||
| City: | BRYSON CITY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287131693 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3369670004 | ||||||||
| FaxNumber: | 8285384441 | ||||||||
| Practice Location | |||||||||
| Address1: | 207 E MEADOW RD STE 1 | ||||||||
| Address2: | |||||||||
| City: | EDEN | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272883469 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3366273194 | ||||||||
| FaxNumber: | 3366273208 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2011 | ||||||||
| LastUpdateDate: | 10/22/2021 | ||||||||
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| AuthorizedOfficialLastName: | BEAVERS | ||||||||
| AuthorizedOfficialFirstName: | CLARENCE | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3366273194 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 10/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 39543 | NC | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | DR4608 | 01 | NC | RAILROAD MEDICARE | OTHER | 5917187 | 05 | NC | MEDICAID |