Provider Demographics
NPI:1154712958
Name:ATLANTA DERMATOLOGY & AESTHETICS PC
Entity type:Organization
Organization Name:ATLANTA DERMATOLOGY & AESTHETICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SUMAYAH
Authorized Official - Middle Name:
Authorized Official - Last Name:TALIAFERRO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-873-1795
Mailing Address - Street 1:PO BOX 79343
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30357-7343
Mailing Address - Country:US
Mailing Address - Phone:404-873-1795
Mailing Address - Fax:
Practice Address - Street 1:232 19TH ST NW
Practice Address - Street 2:SUITE 7230
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30363-1130
Practice Address - Country:US
Practice Address - Phone:404-873-1795
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-15
Last Update Date:2015-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA059337207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
2021072544Medicare NSC