Healthcare Provider Details

I. General information

NPI: 1376584268
Provider Name (Legal Business Name): ATLANTA DERMATOLOGY, VEIN & RESEARCH CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 03/09/2023
Certification Date: 03/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11800 ATLANTIS PL
ALPHARETTA GA
30022-1160
US

IV. Provider business mailing address

11800 ATLANTIS PL
ALPHARETTA GA
30022-1160
US

V. Phone/Fax

Practice location:
  • Phone: 770-360-8881
  • Fax: 770-255-2533
Mailing address:
  • Phone: 770-360-8881
  • Fax: 770-255-2533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: TIFFANI K. HAMILTON
Title or Position: OWNER
Credential: MD
Phone: 770-360-8881