1427614577 NPI number — GEORGIA DERMATOLOGY & SKIN CANCER CENTER, LLC

Table of content: (NPI 1427614577)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427614577 NPI number — GEORGIA DERMATOLOGY & SKIN CANCER CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GEORGIA DERMATOLOGY & SKIN CANCER CENTER, 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:
1427614577
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/14/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2400 BELLEVUE RD STE #21-A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DUBLIN
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31021-2890
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
478-328-0281
Provider Business Mailing Address Fax Number:
478-328-0438

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2110 WOODSIDE EXECUTIVE COURT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AIKEN
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29803-3809
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-644-8900
Provider Business Practice Location Address Fax Number:
803-644-8995
Provider Enumeration Date:
05/14/2019

Additional Information

Authorized Official

Authorized Official Last Name:
SHARKEY
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
478-275-7202

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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