Provider Demographics
NPI:1538465323
Name:DERMATOLOGY ASSOCIATES OF DOTHAN, LLC
Entity Type:Organization
Organization Name:DERMATOLOGY ASSOCIATES OF DOTHAN, LLC
Other - Org Name:DERMATOLOGY ASSOCIATES OF DOTHAN
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:PYNES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:334-793-9222
Mailing Address - Street 1:2431 W MAIN ST STE 501
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36301-1274
Mailing Address - Country:US
Mailing Address - Phone:334-793-9222
Mailing Address - Fax:334-671-0322
Practice Address - Street 1:101 PROFESSIONAL LN
Practice Address - Street 2:
Practice Address - City:ENTERPRISE
Practice Address - State:AL
Practice Address - Zip Code:36330-2085
Practice Address - Country:US
Practice Address - Phone:334-347-3404
Practice Address - Fax:334-671-0322
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DERMATOLOGY ASSOCIATES OF DOTHAN
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-01-27
Last Update Date:2011-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL8834174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51007184OtherBCBS OF ALABAMA
AL529932951Medicaid
AL510G700078Medicare PIN
AL529932951Medicaid