Healthcare Provider Details

I. General information

NPI: 1417280538
Provider Name (Legal Business Name): SKIN DIAGNOSTICS GROUP PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2009
Last Update Date: 07/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3512 OLD MONTGOMERY HWY
BIRMINGHAM AL
35209-5706
US

IV. Provider business mailing address

3512 OLD MONTGOMERY HWY
BIRMINGHAM AL
35209-5706
US

V. Phone/Fax

Practice location:
  • Phone: 205-879-2260
  • Fax: 205-879-2261
Mailing address:
  • Phone: 205-879-2260
  • Fax: 205-879-2261

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License Number25042
License Number StateAL

VIII. Authorized Official

Name: DR. JAMES ALAN LONG
Title or Position: PRESIDENT
Credential: MD
Phone: 205-879-2260