Provider Demographics
NPI:1134544679
Name:MEDICAL DERMATOLOGY SPECIALISTS,PC
Entity type:Organization
Organization Name:MEDICAL DERMATOLOGY SPECIALISTS,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:D
Authorized Official - Last Name:WEISMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-939-9220
Mailing Address - Street 1:5730 GLENRIDGE DR
Mailing Address - Street 2:SUITE T-100
Mailing Address - City:SANDY SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30328-6141
Mailing Address - Country:US
Mailing Address - Phone:404-939-9220
Mailing Address - Fax:404-939-9221
Practice Address - Street 1:5730 GLENRIDGE DR
Practice Address - Street 2:SUITE T-100
Practice Address - City:SANDY SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30328-6141
Practice Address - Country:US
Practice Address - Phone:404-939-9220
Practice Address - Fax:404-939-9221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-20
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA50088261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA07BBSSTOtherMEDICARE ID
GA202I075875OtherMEDICARE PTAN
GA070016848OtherMEDICARE RAILROAD
GA202I075875OtherMEDICARE PTAN