Provider Demographics
NPI:1336361005
Name:ATHENS DERMATOLOGY GROUP PC
Entity type:Organization
Organization Name:ATHENS DERMATOLOGY GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:R
Authorized Official - Last Name:MAFFEI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-769-1550
Mailing Address - Street 1:1050 THOMAS AVE
Mailing Address - Street 2:
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677-6071
Mailing Address - Country:US
Mailing Address - Phone:706-769-1550
Mailing Address - Fax:706-769-1514
Practice Address - Street 1:1050 THOMAS AVE
Practice Address - Street 2:
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677-6071
Practice Address - Country:US
Practice Address - Phone:706-769-1550
Practice Address - Fax:706-769-1514
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA035943207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAG54714Medicare UPIN
GAGRP4227Medicare ID - Type Unspecified