Provider Demographics
NPI:1982010716
Name:RIVERSIDE DERMATOLOGY AND AESTHETIC CENTER, PC
Entity Type:Organization
Organization Name:RIVERSIDE DERMATOLOGY AND AESTHETIC CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:FUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-257-4189
Mailing Address - Street 1:2045 CENTRE STONE CT
Mailing Address - Street 2:SUITE B
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-4571
Mailing Address - Country:US
Mailing Address - Phone:706-257-4189
Mailing Address - Fax:
Practice Address - Street 1:2045 CENTRE STONE CT
Practice Address - Street 2:SUITE B
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-4571
Practice Address - Country:US
Practice Address - Phone:706-257-4189
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-01
Last Update Date:2014-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA70111207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty