Basic Information
| Provider Information | |||||||||
| NPI: | 1720225501 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHARLOTTE DERMATOLOGY,PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2630 E SEVENTH ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282044318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043646110 | ||||||||
| FaxNumber: | 7043644245 | ||||||||
| Practice Location | |||||||||
| Address1: | 660 SINGLETON RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | CONWAY | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295269154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8669853376 | ||||||||
| FaxNumber: | 7043644245 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/15/2009 | ||||||||
| LastUpdateDate: | 01/15/2009 | ||||||||
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| AuthorizedOfficialLastName: | SLAUGHTER | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7043646110 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 31329 | SC | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.