Provider Demographics
NPI:1790708154
Name:DERMATOLOGY AND SKIN SURGERY CLINIC
Entity Type:Organization
Organization Name:DERMATOLOGY AND SKIN SURGERY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:B
Authorized Official - Last Name:INGRISH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-449-8600
Mailing Address - Street 1:201 4TH ST # 30127
Mailing Address - Street 2:SUITE 4-B
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71301-8421
Mailing Address - Country:US
Mailing Address - Phone:318-449-8600
Mailing Address - Fax:318-449-1461
Practice Address - Street 1:201 4TH ST
Practice Address - Street 2:SUITE 4B
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301-8421
Practice Address - Country:US
Practice Address - Phone:318-449-8600
Practice Address - Fax:318-449-1461
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-26
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LACI9696OtherRAILROAD MEDICARE
LACI9696OtherRAILROAD MEDICARE