Provider Demographics
NPI:1437498185
Name:NORTHEAST GEORGIA DERMATOLOGY, PC
Entity Type:Organization
Organization Name:NORTHEAST GEORGIA DERMATOLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PERRY
Authorized Official - Middle Name:J
Authorized Official - Last Name:SCALLAN
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD FACP
Authorized Official - Phone:706-781-1600
Mailing Address - Street 1:204 GAINESVILLE HWY
Mailing Address - Street 2:
Mailing Address - City:BLAIRSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30512-4512
Mailing Address - Country:US
Mailing Address - Phone:706-781-1600
Mailing Address - Fax:706-835-2794
Practice Address - Street 1:204 GAINESVILLE HWY
Practice Address - Street 2:
Practice Address - City:BLAIRSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30512-4512
Practice Address - Country:US
Practice Address - Phone:706-781-1600
Practice Address - Fax:706-835-2794
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-31
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA033190174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA07BBSLHMedicare PIN