1295007185 NPI number — SAVANNAH SKIN PATHOLOGY LLC

Table of content: (NPI 1295007185)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295007185 NPI number — SAVANNAH SKIN PATHOLOGY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SAVANNAH SKIN PATHOLOGY LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295007185
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/07/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7001 HODGSON MEMORIAL DR
Provider Second Line Business Mailing Address:
SUITE 5
Provider Business Mailing Address City Name:
SAVANNAH
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31406-2549
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-799-8598
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16 MULBERRY BLUFF DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAVANNAH
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31406-3268
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-799-8598
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/07/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HOLLAND
Authorized Official First Name:
SUSAN
Authorized Official Middle Name:
K
Authorized Official Title or Position:
DERMATOPATHOLOGIST/LABORATORY DIREC
Authorized Official Telephone Number:
706-799-8598

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  64562 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)