Healthcare Provider Details

I. General information

NPI: 1932280229
Provider Name (Legal Business Name): COLUMBUS DERMATOLOGY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7301 BLACKMON RD
COLUMBUS GA
31909-4478
US

IV. Provider business mailing address

7301 BLACKMON RD
COLUMBUS GA
31909-4478
US

V. Phone/Fax

Practice location:
  • Phone: 706-568-2700
  • Fax: 706-568-2705
Mailing address:
  • Phone: 706-568-2700
  • Fax: 706-568-2705

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number6696501
License Number StateGA

VIII. Authorized Official

Name: ANNE GAGNE
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 706-568-2700