Provider Demographics
NPI:1205518875
Name:PROSYNERGY DERMATOLOGY LLC
Entity type:Organization
Organization Name:PROSYNERGY DERMATOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO AND PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:MELVIN
Authorized Official - Last Name:SQUIRES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-432-9285
Mailing Address - Street 1:111 DAVIS RD
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30907-2383
Mailing Address - Country:US
Mailing Address - Phone:706-432-9285
Mailing Address - Fax:706-432-9674
Practice Address - Street 1:111 DAVIS RD
Practice Address - Street 2:
Practice Address - City:MARTINEZ
Practice Address - State:GA
Practice Address - Zip Code:30907-2383
Practice Address - Country:US
Practice Address - Phone:706-432-9285
Practice Address - Fax:706-432-9674
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-03
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty