Provider Demographics
NPI:1326347238
Name:THACKER DERMATOLOGY LLC
Entity Type:Organization
Organization Name:THACKER DERMATOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BETSY
Authorized Official - Middle Name:
Authorized Official - Last Name:PERRY THACKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-469-4383
Mailing Address - Street 1:4233 CAMELOT CROSSING
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602
Mailing Address - Country:US
Mailing Address - Phone:229-469-4383
Mailing Address - Fax:229-469-4584
Practice Address - Street 1:4233 CAMELOT CROSSING
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602
Practice Address - Country:US
Practice Address - Phone:229-469-4383
Practice Address - Fax:229-469-4584
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-17
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty