Provider Demographics
NPI:1932300084
Name:ATLANTA DERMATOLOGY & SURGERY P.A.
Entity Type:Organization
Organization Name:ATLANTA DERMATOLOGY & SURGERY P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-296-8000
Mailing Address - Street 1:1462 MONTREAL RD
Mailing Address - Street 2:SUITE 411
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-6929
Mailing Address - Country:US
Mailing Address - Phone:404-296-8000
Mailing Address - Fax:770-493-6842
Practice Address - Street 1:1462 MONTREAL RD
Practice Address - Street 2:SUITE 411
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-6929
Practice Address - Country:US
Practice Address - Phone:404-296-8000
Practice Address - Fax:770-493-6842
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-29
Last Update Date:2015-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA011850174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP1071Medicare UPIN