Provider Demographics
NPI:1104176700
Name:PURE DERMATOLOGY & AESTHETICS, PC
Entity type:Organization
Organization Name:PURE DERMATOLOGY & AESTHETICS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:SHANNON
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:205-682-8022
Mailing Address - Street 1:5346 STADIUM TRACE PKWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:HOOVER
Mailing Address - State:AL
Mailing Address - Zip Code:35244-4582
Mailing Address - Country:US
Mailing Address - Phone:205-682-8022
Mailing Address - Fax:
Practice Address - Street 1:5346 STADIUM TRACE PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:HOOVER
Practice Address - State:AL
Practice Address - Zip Code:35244-4582
Practice Address - Country:US
Practice Address - Phone:205-682-8022
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-12
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL21915207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty