Provider Demographics
NPI:1417910431
Name:ATLANTA CENTER FOR DERMATOLOGIC DISEASES PC
Entity Type:Organization
Organization Name:ATLANTA CENTER FOR DERMATOLOGIC DISEASES PC
Other - Org Name:DRS D LEVINE J SILYERSTEIN M FISHER M WEIL K ELLNER
Other - Org Type:Other Name
Authorized Official - Title/Position:BOOKKEEPING INSURANCE
Authorized Official - Prefix:MS
Authorized Official - First Name:ANITA
Authorized Official - Middle Name:
Authorized Official - Last Name:REINER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-751-1433
Mailing Address - Street 1:1265 UPPER HEMBREE RD
Mailing Address - Street 2:STE 100
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-1143
Mailing Address - Country:US
Mailing Address - Phone:770-751-1433
Mailing Address - Fax:770-751-7410
Practice Address - Street 1:1265 UPPER HEMBREE RD
Practice Address - Street 2:STE 100
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-1143
Practice Address - Country:US
Practice Address - Phone:770-751-1433
Practice Address - Fax:770-751-7410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-10
Last Update Date:2012-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA027080207N00000X
GA032990207N00000X
GA034135207N00000X
GA044141207N00000X
GA032377207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
D45942OtherPRUCARE SELECT
D45942OtherPRUDENTIAL HMD AFFILIAT
237691OtherSTATE OF GEORGIA
045942OtherFAMILY PLUS
237691OtherBCBS BLUE CROSS
472244OtherAETNA US HEALTH CARE
CM0095OtherRR MEDICARE
104004OtherHMO PARTNERS
070004931OtherRR MEDICARE
0306784OtherHMO HEALTH FIRST
077541037OtherCHAMPUS
D45942OtherPRUCARE PLUS
D45942OtherEMORY CARE
1751OtherHMO GEORGIA NETWORK
CM0095OtherRR MEDICARE
D45942OtherPRUCARE PLUS
D45942OtherPRUDENTIAL HMD AFFILIAT
=========OtherGENERAL
=========OtherHMO CIGNA
GRP863Medicare ID - Type UnspecifiedGRP