Provider Demographics
NPI:1124274162
Name:ATHENS DUBLIN AREA DERMATOLOGY, PC
Entity type:Organization
Organization Name:ATHENS DUBLIN AREA DERMATOLOGY, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:A
Authorized Official - Last Name:PASLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-369-7546
Mailing Address - Street 1:PO BOX 168
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30603-0168
Mailing Address - Country:US
Mailing Address - Phone:706-369-7546
Mailing Address - Fax:706-369-6788
Practice Address - Street 1:950 PRINCE AVE
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-2726
Practice Address - Country:US
Practice Address - Phone:706-369-7546
Practice Address - Fax:706-369-6788
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-11
Last Update Date:2008-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA030351207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000369872GMedicaid
GA000369872GMedicaid