Healthcare Provider Details

I. General information

NPI: 1508076969
Provider Name (Legal Business Name): SOUTHWEST GEORGIA DERMATOLOGY, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 OSLER CT
ALBANY GA
31707-0205
US

IV. Provider business mailing address

2401 OSLER CT
ALBANY GA
31707-0205
US

V. Phone/Fax

Practice location:
  • Phone: 229-889-1827
  • Fax: 229-889-0305
Mailing address:
  • Phone: 229-889-1827
  • Fax: 229-889-0305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number035424
License Number StateGA

VIII. Authorized Official

Name: STUART M. GOLDSMITH
Title or Position: PRESIDENT
Credential: M.D.
Phone: 229-889-1827