Provider Demographics
NPI:1053697797
Name:DERMATOLOGY SERVICES OF GEORGIA, PLLC
Entity type:Organization
Organization Name:DERMATOLOGY SERVICES OF GEORGIA, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:S
Authorized Official - Last Name:RICHARDS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:478-472-8178
Mailing Address - Street 1:909 BROKEN ARROW TRL
Mailing Address - Street 2:
Mailing Address - City:PERRY
Mailing Address - State:GA
Mailing Address - Zip Code:31069-6800
Mailing Address - Country:US
Mailing Address - Phone:478-472-8178
Mailing Address - Fax:
Practice Address - Street 1:909 BROKEN ARROW TRL
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:GA
Practice Address - Zip Code:31069-6800
Practice Address - Country:US
Practice Address - Phone:478-472-8178
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-26
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA058316207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAH93049Medicare UPIN