Provider Demographics
NPI:1912018839
Name:ATLANTIC SHORE DERMATOLOGY LLC
Entity Type:Organization
Organization Name:ATLANTIC SHORE DERMATOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:C
Authorized Official - Last Name:CAVALIER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-634-4966
Mailing Address - Street 1:2485 DEMERE RD # C100
Mailing Address - Street 2:
Mailing Address - City:ST SIMONS ISLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31522-5634
Mailing Address - Country:US
Mailing Address - Phone:912-634-4966
Mailing Address - Fax:
Practice Address - Street 1:2485 DEMERE RD # C100
Practice Address - Street 2:
Practice Address - City:ST SIMONS ISLAND
Practice Address - State:GA
Practice Address - Zip Code:31522-5634
Practice Address - Country:US
Practice Address - Phone:912-634-4966
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GRP7446Medicare ID - Type Unspecified