Healthcare Provider Details

I. General information

NPI: 1851703391
Provider Name (Legal Business Name): INTEGRATED DERMATOLOGY OF HICKORY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2014
Last Update Date: 06/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1870 N CENTER ST
HICKORY NC
28601-1853
US

IV. Provider business mailing address

902 CLINT MOORE RD 226
BOCA RATON FL
33487-2800
US

V. Phone/Fax

Practice location:
  • Phone: 828-322-7546
  • Fax:
Mailing address:
  • Phone: 561-314-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: JEFFREY D. QUEEN
Title or Position: MANAGER
Credential:
Phone: 561-314-2000