Healthcare Provider Details

I. General information

NPI: 1447803424
Provider Name (Legal Business Name): GALLOWAY DERMATOLOGIC SURGERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2019
Last Update Date: 07/18/2022
Certification Date: 07/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 OLD MILTON PKWY STE C465
ALPHARETTA GA
30005-4429
US

IV. Provider business mailing address

3400 OLD MILTON PKWY STE C465
ALPHARETTA GA
30005-4429
US

V. Phone/Fax

Practice location:
  • Phone: 678-888-4460
  • Fax: 678-888-5533
Mailing address:
  • Phone: 678-888-4460
  • Fax: 678-888-5533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: TREPHINA GALLOWAY
Title or Position: OWNER PHYSICIAN
Credential: DO
Phone: 678-888-4460