Provider Demographics
NPI:1467641381
Name:NORTHWEST GEORGIA DERMATOLOGY & SKIN SURGERY CENTER PC
Entity Type:Organization
Organization Name:NORTHWEST GEORGIA DERMATOLOGY & SKIN SURGERY CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:L
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-235-7711
Mailing Address - Street 1:103 JOHN MADDOX DR NW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-1419
Mailing Address - Country:US
Mailing Address - Phone:706-235-7711
Mailing Address - Fax:706-235-9944
Practice Address - Street 1:103 JOHN MADDOX DR NW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-1419
Practice Address - Country:US
Practice Address - Phone:706-235-7711
Practice Address - Fax:706-235-9944
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-16
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA032302207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000398384AMedicaid
GA000398384AMedicaid
GAB61951Medicare UPIN