Provider Demographics
NPI:1841632783
Name:DERMPATH AND DERM CONSULTANTS
Entity type:Organization
Organization Name:DERMPATH AND DERM CONSULTANTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:J
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-291-0379
Mailing Address - Street 1:1428 SCOTT BLVD
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-1424
Mailing Address - Country:US
Mailing Address - Phone:678-904-4932
Mailing Address - Fax:404-370-0428
Practice Address - Street 1:1428 SCOTT BLVD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-1424
Practice Address - Country:US
Practice Address - Phone:678-904-4932
Practice Address - Fax:404-370-0428
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-19
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA053035207ND0900X
SC27516291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes291U00000XLaboratoriesClinical Medical Laboratory
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
H30232Medicare UPIN