Active NPI
Polley Clinic of Dermatology & Dermatologic Surgery
- Dermatopathology Physician
- Wilson, NC
National Provider Identifier
1104847714
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dermatopathology Physician
- License
- 27881
- Legal business name
- POLLEY CLINIC OF DERMATOLOGY & DERMATOLOGIC SURGERY
- Practice address
- 1806 Glendale Dr SW
Wilson, NC 27893-4402 - Phone
- (252) 243-0566
- Fax
- (252) 243-1347
- NPI assigned
- Jul 21, 2006
- Organization subpart
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Authorized official
- Name
- Kelli Newman
- Title
- Credentialing Specialist
- Phone
- (252) 668-7026
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dermatopathology Physician | 207ND0900X | 27881 | NC | Primary |
Addresses
Primary practice location
1806 Glendale Dr SW
Wilson, NC 27893-4402
Mailing address
1806 Glendale Dr SW
Wilson, NC 27893-4402
Phone (252) 243-0566
Other identifiers 9
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 2222414 | Other | NC | FIRST HEALTH |
| 0296G | Other | NC | BCBS OF NC |
| 785505 | Other | NC | UNITED HEALTH CARE |
| 68327 | Other | NC | ACCORDIA |
| 7068303 | Other | NC | CIGNA |
| 7257619 | Other | NC | AETNA |
| 890296G | Medicaid | NC | |
| DE4848 | Other | NC | RAIL ROAD MEDICARE |
| 99494 | Other | NC | MEDCOST |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in NC
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20041122001191 | NC | Part B Supplier - Clinic/Group Practice | 9638134364 |
Receives reassigned benefits from 14 practitioners Practice locations: Smithfield, NC; Wilson, NC; Rocky Mount, NC; Roanoke Rapids, NC; Goldsboro, NC; Fayetteville, NC |
National Provider Directory
National Provider DirectoryLocations
106 Barcelona Dr
Fayetteville, NC 28303
Phone (252) 243-0566
110 Long Cir
Roanoke Rapids, NC 27870
Phone (252) 243-0156
131 Foy Dr
Rocky Mount, NC 27804
Phone (252) 243-0566
3516 US Highway 301 S
Smithfield, NC 27577
Phone (252) 243-0566
1806 Glendale Dr SW
Wilson, NC 27893
Phone (252) 243-0566
Practitioners & affiliated clinicians
Practitioners 15
Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1153440000000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1628035200000",
"number": "1104847714",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1806 GLENDALE DR SW",
"city": "WILSON",
"state": "NC",
"postal_code": "278934402",
"telephone_number": "252-243-0566",
"fax_number": "252-243-1347"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1806 GLENDALE DR SW",
"city": "WILSON",
"state": "NC",
"postal_code": "278934402",
"telephone_number": "252-243-0566",
"fax_number": "252-243-1347"
}
],
"practiceLocations": [],
"basic": {
"organization_name": "POLLEY CLINIC OF DERMATOLOGY & DERMATOLOGIC SURGERY",
"organizational_subpart": "NO",
"enumeration_date": "2006-07-21",
"last_updated": "2021-08-04",
"certification_date": "2020-08-06",
"status": "A",
"authorized_official_last_name": "NEWMAN",
"authorized_official_first_name": "KELLI",
"authorized_official_title_or_position": "CREDENTIALING SPECIALIST",
"authorized_official_telephone_number": "252-668-7026"
},
"taxonomies": [
{
"code": "207ND0900X",
"taxonomy_group": "193400000X SINGLE SPECIALTY GROUP",
"desc": "Dermatology, Dermatopathology",
"state": "NC",
"license": "27881",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "FIRST HEALTH",
"identifier": "2222414",
"state": "NC"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BCBS OF NC",
"identifier": "0296G",
"state": "NC"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "UNITED HEALTH CARE",
"identifier": "785505",
"state": "NC"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "ACCORDIA",
"identifier": "68327",
"state": "NC"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "CIGNA",
"identifier": "7068303",
"state": "NC"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "AETNA",
"identifier": "7257619",
"state": "NC"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "890296G",
"state": "NC"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "RAIL ROAD MEDICARE",
"identifier": "DE4848",
"state": "NC"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "MEDCOST",
"identifier": "99494",
"state": "NC"
}
],
"endpoints": [],
"other_names": []
}Other providers in Wilson, NC
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 4, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.