1134544679 NPI number — MEDICAL DERMATOLOGY SPECIALISTS,PC

Table of content: (NPI 1134544679)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134544679 NPI number — MEDICAL DERMATOLOGY SPECIALISTS,PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDICAL DERMATOLOGY SPECIALISTS,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:
1134544679
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/31/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5730 GLENRIDGE DR
Provider Second Line Business Mailing Address:
SUITE T-100
Provider Business Mailing Address City Name:
SANDY SPRINGS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30328-6141
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-939-9220
Provider Business Mailing Address Fax Number:
404-939-9221

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5730 GLENRIDGE DR
Provider Second Line Business Practice Location Address:
SUITE T-100
Provider Business Practice Location Address City Name:
SANDY SPRINGS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30328-6141
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-939-9220
Provider Business Practice Location Address Fax Number:
404-939-9221
Provider Enumeration Date:
02/20/2014

Additional Information

Authorized Official

Authorized Official Last Name:
WEISMAN
Authorized Official First Name:
JAMIE
Authorized Official Middle Name:
D
Authorized Official Title or Position:
PHYSICIAN/OWNER
Authorized Official Telephone Number:
404-939-9220

Provider Taxonomy Codes

  • Taxonomy code: 261QM2500X , with the licence number:  50088 , 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)

  • Identifier: 07BBSST . This is a "MEDICARE ID" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 202I075875 . This is a "MEDICARE PTAN" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 070016848 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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