Southeastern Dermatology, PA

Primary specialty

Dermatology PhysicianTaxonomy code 207N00000X

Legal business name

SOUTHEASTERN DERMATOLOGY, PA

Practice address

4390 Fayetteville Rd
Lumberton, NC 28358-2677

Phone

(910) 738-7154

Fax

(910) 738-4455

NPI assigned

Jun 17, 2006

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dr. Andrew Adam Hendricks, MDNPI 1740246115

Title

Medical Director

Phone

(910) 738-7154

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Enrolled in NC

Enrollment records 1

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Locations

Practitioners 8

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Andrew Adam Hendricks, MD

  • Dermatology Physician
  • Lumberton, NC
  • NPI 1740246115
  Medicare reassignment Care Compare group NPD Authorized official
• Katherine Marie Hendricks, MSN, FNP-BC

  • Family Nurse Practitioner
  • Winston Salem, NC
  • NPI 1437570405
  Medicare reassignment Care Compare group NPD
• Peter L Mattei IV, M.D.

  • MOHS-Micrographic Surgery Physician
  • Sarasota, FL
  • NPI 1013195759

  Dermatology, NC

  Medicare reassignment NPD
• Tiffany Anne Clowers, PA-C

  • Medical Physician Assistant
  • Bladenboro, NC
  • NPI 1942667449
  Medicare reassignment
• Jennifer Hunnicutt Taylor, PA-C

  • Physician Assistant
  • Lumberton, NC
  • NPI 1578503868
  Medicare reassignment
• Emily Lopes Townsend, PA-C

  • Physician Assistant
  • Fayetteville, NC
  • NPI 1215477369
  Medicare reassignment
• Tierra Danielle Chavis, NP

  • Nurse Practitioner
  • Fayetteville, NC
  • NPI 1467299925
  NPD
• Mindy Pham, DO

  • Family Medicine Physician
  • Lumberton, NC
  • NPI 1518603810
  NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1150502400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1730332800000",
    "number": "1922043629",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4390 FAYETTEVILLE RD",
            "city": "LUMBERTON",
            "state": "NC",
            "postal_code": "283582677",
            "telephone_number": "910-738-7154",
            "fax_number": "910-738-4455"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4390 FAYETTEVILLE RD",
            "city": "LUMBERTON",
            "state": "NC",
            "postal_code": "283582677",
            "telephone_number": "910-738-7154",
            "fax_number": "910-738-4455"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHEASTERN DERMATOLOGY, PA",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-06-17",
        "last_updated": "2024-10-31",
        "certification_date": "2024-10-31",
        "status": "A",
        "authorized_official_last_name": "HENDRICKS",
        "authorized_official_first_name": "ANDREW",
        "authorized_official_middle_name": "ADAM",
        "authorized_official_title_or_position": "MEDICAL DIRECTOR",
        "authorized_official_telephone_number": "910-738-7154",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dermatology",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "8941520",
            "state": "NC"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Southeastern Health Physician Services
• Southeastern Health Physician Services

• Dermatology Physician in Lumberton, NC
• Providers in Lumberton, NC by specialty
• Dermatology Physician in North Carolina

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 31, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.