Provider Demographics
NPI:1760493167
Name:WEST GEORGIA DERMATOLOGY PC
Entity Type:Organization
Organization Name:WEST GEORGIA DERMATOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARIN
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:BARTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-882-5119
Mailing Address - Street 1:1605 WHITESVILLE ST
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-5903
Mailing Address - Country:US
Mailing Address - Phone:706-882-5119
Mailing Address - Fax:706-882-0270
Practice Address - Street 1:1605 WHITESVILLE ST
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-5903
Practice Address - Country:US
Practice Address - Phone:706-882-5119
Practice Address - Fax:706-882-0270
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2014-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA30949174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA280767OtherBC/BS PROVIDER NUMBER
GA1760493167Medicare PIN