Provider Demographics
NPI:1780872556
Name:ATLANTA SKIN AND AESTHETICS
Entity type:Organization
Organization Name:ATLANTA SKIN AND AESTHETICS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:EDGAR
Authorized Official - Last Name:NIX
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:404-252-4110
Mailing Address - Street 1:1100 JOHNSON FERRY RD STE 465
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1709
Mailing Address - Country:US
Mailing Address - Phone:404-252-4110
Mailing Address - Fax:404-252-2188
Practice Address - Street 1:5671 PEACHTREE DUNWOODY RD STE 660
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-5006
Practice Address - Country:US
Practice Address - Phone:404-252-4110
Practice Address - Fax:404-252-2188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-05
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA07BDBCPMedicare PIN
GAGRP3844Medicare PIN