Healthcare Provider Details

I. General information

NPI: 1609927623
Provider Name (Legal Business Name): NEW AGE DERMATOLOGY CENTER PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 10/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1091 PEMBERTON HILL RD STE 201
APEX NC
27502-4269
US

IV. Provider business mailing address

1091 PEMBERTON HILL RD STE 201
APEX NC
27502-4269
US

V. Phone/Fax

Practice location:
  • Phone: 919-367-3625
  • Fax: 919-367-3608
Mailing address:
  • Phone: 919-367-3625
  • Fax: 919-367-3608

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number2000-00747
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier129ER
Identifier TypeOTHER
Identifier StateNC
Identifier IssuerBLUE CROSS BLUE SHEILD
# 2
Identifier89129ER
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer

VIII. Authorized Official

Name: DR. MICSUNICA ELVIRA CHIRITESCU
Title or Position: PHYSICIAN OWNER
Credential: MD
Phone: 919-624-2802