Provider Demographics
NPI:1174680979
Name:ATLANTA WEST DERMATOLOGY, P.C.
Entity Type:Organization
Organization Name:ATLANTA WEST DERMATOLOGY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRAC ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:HOLLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:GARRETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-446-1447
Mailing Address - Street 1:1550 MULKEY RD
Mailing Address - Street 2:
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30106-1112
Mailing Address - Country:US
Mailing Address - Phone:770-732-1137
Mailing Address - Fax:770-732-2081
Practice Address - Street 1:1550 MULKEY RD
Practice Address - Street 2:
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-1112
Practice Address - Country:US
Practice Address - Phone:770-732-1137
Practice Address - Fax:770-732-2081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2010-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA028477207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP3970Medicare ID - Type Unspecified