Provider Demographics
NPI:1689954372
Name:BLUE RIDGE DERMATOLOGY
Entity Type:Organization
Organization Name:BLUE RIDGE DERMATOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:R
Authorized Official - Last Name:MILLS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-946-4227
Mailing Address - Street 1:101 RIVERSTONE VIS
Mailing Address - Street 2:STE 215
Mailing Address - City:BLUE RIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30513-6648
Mailing Address - Country:US
Mailing Address - Phone:706-946-4227
Mailing Address - Fax:706-258-4175
Practice Address - Street 1:101 RIVERSTONE VIS
Practice Address - Street 2:STE 215
Practice Address - City:BLUE RIDGE
Practice Address - State:GA
Practice Address - Zip Code:30513-6648
Practice Address - Country:US
Practice Address - Phone:706-946-4227
Practice Address - Fax:706-258-4175
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-25
Last Update Date:2011-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA056316207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty