Provider Demographics
NPI:1942307160
Name:GEORIGA DERMATOLOGY CENTER, P.C.
Entity Type:Organization
Organization Name:GEORIGA DERMATOLOGY CENTER, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:S
Authorized Official - Last Name:GROSS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-781-5077
Mailing Address - Street 1:1505 NORTHSIDE BLVD
Mailing Address - Street 2:SUITE 1500
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-7623
Mailing Address - Country:US
Mailing Address - Phone:770-781-5077
Mailing Address - Fax:770-781-3915
Practice Address - Street 1:1505 NORTHSIDE BLVD
Practice Address - Street 2:SUITE 1500
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-7623
Practice Address - Country:US
Practice Address - Phone:770-781-5077
Practice Address - Fax:770-781-3915
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2016-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA030078207N00000X
GA003130363A00000X
GARN164556363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA621341781AMedicaid
GA000509858DMedicaid
GA621341781AMedicaid
GA621341781AMedicaid