Provider Demographics
NPI:1073624763
Name:JAMES T. SANDWICH, M.D., P.C.
Entity Type:Organization
Organization Name:JAMES T. SANDWICH, M.D., P.C.
Other - Org Name:FAYETTE AREA DERMATOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:SANDWICH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-460-6194
Mailing Address - Street 1:450 LANIER AVE W
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-1502
Mailing Address - Country:US
Mailing Address - Phone:770-460-8988
Mailing Address - Fax:770-460-0727
Practice Address - Street 1:450 LANIER AVE W
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-1502
Practice Address - Country:US
Practice Address - Phone:770-460-8988
Practice Address - Fax:770-460-0727
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA36609174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAF54519Medicare UPIN
11BDMWRMedicare PIN