Provider Demographics
NPI:1770782849
Name:DECATUR DERMATOLOGY, PC
Entity type:Organization
Organization Name:DECATUR DERMATOLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ERIN
Authorized Official - Middle Name:K
Authorized Official - Last Name:STEWART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-353-7775
Mailing Address - Street 1:1316 SOMERVILLE RD SE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35601-4305
Mailing Address - Country:US
Mailing Address - Phone:256-353-7775
Mailing Address - Fax:256-353-7765
Practice Address - Street 1:1316 SOMERVILLE RD SE
Practice Address - Street 2:SUITE 4
Practice Address - City:DECATUR
Practice Address - State:AL
Practice Address - Zip Code:35601-4305
Practice Address - Country:US
Practice Address - Phone:256-353-7775
Practice Address - Fax:256-353-7765
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-17
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00026547207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALI25671Medicare UPIN