Provider Demographics
NPI:1134217342
Name:NORTH GEORGIA DERMATOPATHOLOGY PC
Entity type:Organization
Organization Name:NORTH GEORGIA DERMATOPATHOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:LINDSAY
Authorized Official - Middle Name:CATHERINE
Authorized Official - Last Name:JERDAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-426-0827
Mailing Address - Street 1:PO BOX 162406
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30321-2406
Mailing Address - Country:US
Mailing Address - Phone:770-426-0827
Mailing Address - Fax:770-426-9534
Practice Address - Street 1:945 CHURCH STREET EXT NE STE B
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-7293
Practice Address - Country:US
Practice Address - Phone:770-426-0827
Practice Address - Fax:770-426-9534
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2010-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA11D0645784291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA52023957OtherBCBS
GA434544295AMedicaid
GA434544295AMedicaid