Provider Demographics
NPI:1417007212
Name:MARIETTA DERMATOLOGY ASSOCIATES PA
Entity Type:Organization
Organization Name:MARIETTA DERMATOLOGY ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF BILLING OFFICE
Authorized Official - Prefix:MRS
Authorized Official - First Name:GOBIN
Authorized Official - Middle Name:
Authorized Official - Last Name:COPPA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-422-1013
Mailing Address - Street 1:111 MARBLE MILL RD NW
Mailing Address - Street 2:MARIETTA DERMATOLOGY ASSOCIATES PA
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-1047
Mailing Address - Country:US
Mailing Address - Phone:770-422-1013
Mailing Address - Fax:770-514-5996
Practice Address - Street 1:111 MARBLE MILL RD NW
Practice Address - Street 2:MARIETTA DERMATOLOGY ASSOCIATES PA
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1047
Practice Address - Country:US
Practice Address - Phone:770-422-1013
Practice Address - Fax:770-514-5996
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CM6753OtherMEDICARE RAILROAD
1584Medicare ID - Type Unspecified
CM6753Medicare ID - Type UnspecifiedRAILROAD MEDICARE