Organization
DERMATOLOGY CENTER OF HICKORY, PA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. JERRY LEE PRUITT M.D. (PRESIDENT)
(828) 328-3500
Entity
Organization
Contact information
Practice address
245 11TH AVE NE, HICKORY, NC 28601-3885
(828) 328-3500
(828) 328-8777
Mailing address
245 11TH AVE NE, HICKORY, NC 28601-3885
(828) 328-3500
(828) 328-8777
Taxonomy
Speciality
Code
Description
License number
State
207N00000X
Dermatology Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
070015170
RR MEDICARE
NC
01
—
69390
BLUE CROSS BLUE SHIELD OF NORTH CAROLINA
NC
Enumeration date
06/30/2010
Last updated
07/05/2011
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