Provider Demographics
NPI:1407215817
Name:SKIN CENTER OF GEORGIA, PC
Entity Type:Organization
Organization Name:SKIN CENTER OF GEORGIA, PC
Other - Org Name:GEORGIA SKIN CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:CAUDELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-201-6324
Mailing Address - Street 1:PO BOX 1456
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30503-1456
Mailing Address - Country:US
Mailing Address - Phone:770-535-7546
Mailing Address - Fax:770-535-7591
Practice Address - Street 1:1250 JESSE JEWELL PKWY SE
Practice Address - Street 2:SUITE 500
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3871
Practice Address - Country:US
Practice Address - Phone:770-535-7546
Practice Address - Fax:770-535-7591
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-12
Last Update Date:2016-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA058402207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101343342Medicaid
PA101343342Medicaid