1174680979 NPI number — ATLANTA WEST DERMATOLOGY & SURGERY CENTER PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174680979 NPI number — ATLANTA WEST DERMATOLOGY & SURGERY CENTER PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ATLANTA WEST DERMATOLOGY & SURGERY 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:
1174680979
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/12/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1550 MULKEY RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AUSTELL
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30106-1112
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-732-1137
Provider Business Mailing Address Fax Number:
770-732-2081

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1550 MULKEY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AUSTELL
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30106-1112
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-732-1137
Provider Business Practice Location Address Fax Number:
770-732-2081
Provider Enumeration Date:
01/02/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HALL
Authorized Official First Name:
CHRISTY
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
770-732-1137

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , with the licence number:  028477 , 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)





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