Provider Demographics
NPI:1346792538
Name:CLARKESVILLE DERMATOLOGY & MEDICAL ASSOCIATES LLC
Entity type:Organization
Organization Name:CLARKESVILLE DERMATOLOGY & MEDICAL ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:B
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:706-754-5991
Mailing Address - Street 1:5330 HIGHWAY 115
Mailing Address - Street 2:
Mailing Address - City:CLARKESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30523-6730
Mailing Address - Country:US
Mailing Address - Phone:706-754-5991
Mailing Address - Fax:706-754-6736
Practice Address - Street 1:5330 HIGHWAY 115
Practice Address - Street 2:
Practice Address - City:CLARKESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30523-6730
Practice Address - Country:US
Practice Address - Phone:706-754-5991
Practice Address - Fax:706-754-6736
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-04
Last Update Date:2018-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty