Provider Demographics
NPI:1114022167
Name:SKIN CANCER SPECIALISTS P C
Entity Type:Organization
Organization Name:SKIN CANCER SPECIALISTS P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/FOUNDER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:CHASTAIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-422-5557
Mailing Address - Street 1:835 COGBURN AVE NW
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-1031
Mailing Address - Country:US
Mailing Address - Phone:770-422-5557
Mailing Address - Fax:770-422-5456
Practice Address - Street 1:835 COGBURN AVE NW
Practice Address - Street 2:SUITE 100
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1031
Practice Address - Country:US
Practice Address - Phone:770-422-5557
Practice Address - Fax:770-422-5456
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2014-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP6036Medicare PIN