Provider Demographics
NPI:1295721512
Name:ALBANY DERMATOLOGY CLINIC, PA
Entity type:Organization
Organization Name:ALBANY DERMATOLOGY CLINIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MELINDA
Authorized Official - Middle Name:F
Authorized Official - Last Name:GREENFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:407-875-2080
Mailing Address - Street 1:151 SOUTHHALL LANE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-7172
Mailing Address - Country:US
Mailing Address - Phone:407-875-2080
Mailing Address - Fax:407-650-3455
Practice Address - Street 1:2709 MEREDYTH DR
Practice Address - Street 2:SUITE 340
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31707-0222
Practice Address - Country:US
Practice Address - Phone:229-883-1130
Practice Address - Fax:229-883-1153
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-22
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA049451207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GACB2415OtherMEDICARE RAILROAD GROUP #
GA300021798AMedicaid
GAGRP1577OtherMEDICARE SECONDARY GRP #
GAGRP1577Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER