Provider Demographics
NPI:1538240486
Name:PIEDMONT DERMATOLOGY CENTER, PC
Entity type:Organization
Organization Name:PIEDMONT DERMATOLOGY CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:NED
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:GROSS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:276-666-8439
Mailing Address - Street 1:314 FAIRY STREET EXT
Mailing Address - Street 2:SUITE D
Mailing Address - City:MARTINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24112-1913
Mailing Address - Country:US
Mailing Address - Phone:276-666-8439
Mailing Address - Fax:276-666-8440
Practice Address - Street 1:314 FAIRY STREET EXT
Practice Address - Street 2:SUITE D
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24112-1913
Practice Address - Country:US
Practice Address - Phone:276-666-8439
Practice Address - Fax:276-666-8440
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101228761174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA070015390OtherRAILROAD MEDICARE
VA9767433OtherCIGNA
VA285584OtherANTHEM
NC89011P5Medicaid
NC7986163OtherAETNA
NCA1547OtherMEDCOST
NC0308562OtherUNITED HEALTHCARE
VAA1547OtherMEDCOST
NC011P5OtherBCBS
NC070015616OtherRAILROAD MEDICARE
VA7986163OtherAETNA
NC9767433OtherCIGNA
VAA1547OtherMEDCOST
NC9767433OtherCIGNA
NC89011P5Medicaid