Healthcare Provider Details

I. General information

NPI: 1104847714
Provider Name (Legal Business Name): POLLEY CLINIC OF DERMATOLOGY & DERMATOLOGIC SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 08/04/2021
Certification Date: 08/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1806 GLENDALE DR SW
WILSON NC
27893-4402
US

IV. Provider business mailing address

1806 GLENDALE DR SW
WILSON NC
27893-4402
US

V. Phone/Fax

Practice location:
  • Phone: 252-243-0566
  • Fax: 252-243-1347
Mailing address:
  • Phone: 252-243-0566
  • Fax: 252-243-1347

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number27881
License Number StateNC

VII. Legacy identifiers

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

# 1
Identifier2222414
Identifier TypeOTHER
Identifier StateNC
Identifier IssuerFIRST HEALTH
# 2
Identifier0296G
Identifier TypeOTHER
Identifier StateNC
Identifier IssuerBCBS OF NC
# 3
Identifier785505
Identifier TypeOTHER
Identifier StateNC
Identifier IssuerUNITED HEALTH CARE
# 4
Identifier68327
Identifier TypeOTHER
Identifier StateNC
Identifier IssuerACCORDIA
# 5
Identifier7068303
Identifier TypeOTHER
Identifier StateNC
Identifier IssuerCIGNA
# 6
Identifier7257619
Identifier TypeOTHER
Identifier StateNC
Identifier IssuerAETNA
# 7
Identifier890296G
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer
# 8
IdentifierDE4848
Identifier TypeOTHER
Identifier StateNC
Identifier IssuerRAIL ROAD MEDICARE
# 9
Identifier99494
Identifier TypeOTHER
Identifier StateNC
Identifier IssuerMEDCOST

VIII. Authorized Official

Name: KELLI NEWMAN
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 252-668-7026