Provider Demographics
NPI:1568533180
Name:ATLANTA CENTER OF DERMATOLOGY AND MEDISPA PC
Entity Type:Organization
Organization Name:ATLANTA CENTER OF DERMATOLOGY AND MEDISPA PC
Other - Org Name:GLORIA CAMPBELL D HUE
Other - Org Type:Other Name
Authorized Official - Title/Position:DERMATOLOGIST PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GLORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMPBELL D HUE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-349-7440
Mailing Address - Street 1:2950 STONE HOGAN CONNECTOR
Mailing Address - Street 2:BUILDING 4
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30331-2837
Mailing Address - Country:US
Mailing Address - Phone:404-349-7440
Mailing Address - Fax:404-349-7402
Practice Address - Street 1:2950 STONE HOGAN CONNECTOR
Practice Address - Street 2:BUILDING 4
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30331-2837
Practice Address - Country:US
Practice Address - Phone:404-349-7440
Practice Address - Fax:404-349-7402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2013-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA024412207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA07BBSQRMedicare ID - Type Unspecified
E57090Medicare UPIN