Provider Demographics
NPI:1932280229
Name:COLUMBUS DERMATOLOGY, PC
Entity Type:Organization
Organization Name:COLUMBUS DERMATOLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:GAGNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-568-2700
Mailing Address - Street 1:7301 BLACKMON RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31909-4478
Mailing Address - Country:US
Mailing Address - Phone:706-568-2700
Mailing Address - Fax:706-568-2705
Practice Address - Street 1:7301 BLACKMON RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31909-4478
Practice Address - Country:US
Practice Address - Phone:706-568-2700
Practice Address - Fax:706-568-2705
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA6696501261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP6720Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER