Healthcare Provider Details

I. General information

NPI: 1497940944
Provider Name (Legal Business Name): MID-CHARLOTTE DERMATOLOGY AND RESEARCH PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2007
Last Update Date: 03/01/2022
Certification Date: 03/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6406 CARMEL RD STE 309
CHARLOTTE NC
28226-8267
US

IV. Provider business mailing address

6406 CARMEL RD STE 309
CHARLOTTE NC
28226-8267
US

V. Phone/Fax

Practice location:
  • Phone: 704-367-9777
  • Fax: 704-367-0504
Mailing address:
  • Phone: 704-367-9777
  • Fax: 704-367-0504

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number23521
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number23521
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number23521
License Number StateNC

VIII. Authorized Official

Name: DR. IRENE ELIZABETH EDWARDS
Title or Position: OWNER
Credential: MD
Phone: 704-367-9777