Provider Demographics
NPI:1558339275
Name:DERMATOLOGY SPECIALISTS OF AUGUSTA, INC
Entity Type:Organization
Organization Name:DERMATOLOGY SPECIALISTS OF AUGUSTA, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-547-0607
Mailing Address - Street 1:1306 CONCOURSE DR STE 201
Mailing Address - Street 2:
Mailing Address - City:LINTHICUM HEIGHTS
Mailing Address - State:MD
Mailing Address - Zip Code:21090-1033
Mailing Address - Country:US
Mailing Address - Phone:813-341-3259
Mailing Address - Fax:813-341-3259
Practice Address - Street 1:1203 TOWN PARK LN
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-3481
Practice Address - Country:US
Practice Address - Phone:706-650-7546
Practice Address - Fax:706-922-9169
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-09
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207N00000X, 207ND0101X, 207NS0135X
GA049686207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP6619Medicare ID - Type Unspecified
GAH80565Medicare UPIN