Provider Demographics
NPI:1376605394
Name:SKIN CANCER & COSMETIC DERMATOLOGY CENTER, PC
Entity Type:Organization
Organization Name:SKIN CANCER & COSMETIC DERMATOLOGY CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MS
Authorized Official - First Name:KELLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:FINNELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-521-1100
Mailing Address - Street 1:136 BATTLEFIELD CROSSING CT
Mailing Address - Street 2:
Mailing Address - City:RINGGOLD
Mailing Address - State:GA
Mailing Address - Zip Code:30736-5176
Mailing Address - Country:US
Mailing Address - Phone:706-277-7311
Mailing Address - Fax:706-529-7210
Practice Address - Street 1:1107 MEMORIAL DR STE 201
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-8662
Practice Address - Country:US
Practice Address - Phone:706-277-7311
Practice Address - Fax:706-272-3512
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP4446OtherMEDICARE GROUP