1063715423 NPI number — SKIN CANCER AND COSMETIC DERMATOLOGY CENTER PC

Table of content: (NPI 1063715423)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063715423 NPI number — SKIN CANCER AND COSMETIC DERMATOLOGY CENTER PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SKIN CANCER AND COSMETIC DERMATOLOGY CENTER PC
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:
1063715423
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/17/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1107 MEMORIAL DR
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
DALTON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30720-8668
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-277-7311
Provider Business Mailing Address Fax Number:
706-272-3512

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 DIXIE LEE CENTER RD
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
KIMBALL
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37347-5672
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-277-7311
Provider Business Practice Location Address Fax Number:
706-272-3512
Provider Enumeration Date:
12/07/2010

Additional Information

Authorized Official

Authorized Official Last Name:
FINNELL
Authorized Official First Name:
KELLEY
Authorized Official Middle Name:
Authorized Official Title or Position:
PRACTICE MANAGER
Authorized Official Telephone Number:
706-277-7311

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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