Provider Demographics
NPI:1588118574
Name:PREMIER DERMATOLOGY AND MOHS SURGERY OF ATLANTA LLC
Entity type:Organization
Organization Name:PREMIER DERMATOLOGY AND MOHS SURGERY OF ATLANTA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-345-1899
Mailing Address - Street 1:3180 N POINT PKWY
Mailing Address - Street 2:STE 420
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30005-4248
Mailing Address - Country:US
Mailing Address - Phone:678-345-1899
Mailing Address - Fax:678-345-1927
Practice Address - Street 1:3180 N POINT PKWY
Practice Address - Street 2:STE 420
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30005-4248
Practice Address - Country:US
Practice Address - Phone:678-345-1899
Practice Address - Fax:678-345-1927
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-08
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA73661207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty