Provider Demographics
NPI:1891064937
Name:DERMATOLOGY ASSOCIATES OF MONTGOMERY, LLC
Entity Type:Organization
Organization Name:DERMATOLOGY ASSOCIATES OF MONTGOMERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:STONE
Authorized Official - Last Name:BARRETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-396-8774
Mailing Address - Street 1:PO BOX 241627
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36124-1627
Mailing Address - Country:US
Mailing Address - Phone:334-396-1555
Mailing Address - Fax:334-396-9833
Practice Address - Street 1:286 MITYLENE PARK DR
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36117-3548
Practice Address - Country:US
Practice Address - Phone:334-396-1555
Practice Address - Fax:334-396-9833
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-19
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL10825174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL528501290Medicaid
ALCM4358OtherRAILROAD MEDICARE
AL528501290Medicaid