Provider Demographics
NPI:1346351582
Name:SKIN CARE PHYSICIANS OF GEORGIA, P.C.
Entity Type:Organization
Organization Name:SKIN CARE PHYSICIANS OF GEORGIA, P.C.
Other - Org Name:DERMATOLOGIC SURGERY SPECIALISTS, P.C.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER, SR PHYSICIAN, CEO
Authorized Official - Prefix:
Authorized Official - First Name:DAVUD
Authorized Official - Middle Name:B
Authorized Official - Last Name:KENT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:478-742-2180
Mailing Address - Street 1:308 COLISEUM DR STE 200
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31217-3861
Mailing Address - Country:US
Mailing Address - Phone:478-742-2180
Mailing Address - Fax:478-745-2623
Practice Address - Street 1:308 COLISEUM DR STE 200
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31217-3861
Practice Address - Country:US
Practice Address - Phone:478-742-2180
Practice Address - Fax:478-745-2623
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP3553Medicare PIN
GAE1128Medicare PIN