Healthcare Provider Details

I. General information

NPI: 1295721512
Provider Name (Legal Business Name): ALBANY DERMATOLOGY CLINIC, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2005
Last Update Date: 04/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2709 MEREDYTH DR SUITE 340
ALBANY GA
31707-0222
US

IV. Provider business mailing address

151 SOUTHHALL LANE SUITE 300
MAITLAND FL
32751-7172
US

V. Phone/Fax

Practice location:
  • Phone: 229-883-1130
  • Fax: 229-883-1153
Mailing address:
  • Phone: 407-875-2080
  • Fax: 407-650-3455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number049451
License Number StateGA

VIII. Authorized Official

Name: MELINDA F. GREENFIELD
Title or Position: PHYSICIAN
Credential: DO
Phone: 407-875-2080