Basic Information
| Provider Information | |||||||||
| NPI: | 1841632783 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DERMPATH AND DERM CONSULTANTS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1428 SCOTT BLVD | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300301424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6789044932 | ||||||||
| FaxNumber: | 4043700428 | ||||||||
| Practice Location | |||||||||
| Address1: | 1428 SCOTT BLVD | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300301424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6789044932 | ||||||||
| FaxNumber: | 4043700428 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2013 | ||||||||
| LastUpdateDate: | 06/13/2014 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | KATHLEEN | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4042910379 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ND0900X | 053035 | GA | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | Dermatopathology | 291U00000X | 27516 | SC | Y | Laboratories | Clinical Medical Laboratory |
No ID Information.