Provider Demographics
NPI:1508920992
Name:SUMMIT DERMATOLOGY & LASER CENTER, P.C.
Entity Type:Organization
Organization Name:SUMMIT DERMATOLOGY & LASER CENTER, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:BLASIK
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:912-262-1801
Mailing Address - Street 1:1111 GLYNCO PKWY
Mailing Address - Street 2:BLDG 1, SUITE 20
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31525-7921
Mailing Address - Country:US
Mailing Address - Phone:912-262-1801
Mailing Address - Fax:912-264-6262
Practice Address - Street 1:1111 GLYNCO PKWY
Practice Address - Street 2:BLDG 1, SUITE 20
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31525-7921
Practice Address - Country:US
Practice Address - Phone:912-262-1801
Practice Address - Fax:912-264-6262
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA055102207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GADB9882OtherRR MEDICARE
GAC65657Medicare UPIN
GAGRP6763Medicare PIN