Provider Demographics
NPI:1649683897
Name:COLQUITT REGIONAL DERMATOLOGY, LLC
Entity type:Organization
Organization Name:COLQUITT REGIONAL DERMATOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER ENROLLMENT COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:L
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-891-9131
Mailing Address - Street 1:760 26TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:MOULTRIE
Mailing Address - State:GA
Mailing Address - Zip Code:31768-6799
Mailing Address - Country:US
Mailing Address - Phone:229-502-9710
Mailing Address - Fax:
Practice Address - Street 1:760 26TH AVE SE
Practice Address - Street 2:
Practice Address - City:MOULTRIE
Practice Address - State:GA
Practice Address - Zip Code:31768-6799
Practice Address - Country:US
Practice Address - Phone:229-502-9710
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COLQUITT REGIONAL MEDICAL, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-06-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty