Healthcare Provider Details

I. General information

NPI: 1063460459
Provider Name (Legal Business Name): GEORGIA DERMATOLOGY & SKIN CANCER CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 10/30/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 BELLEVUE RD 16 ERIN OFFICE PARK
DUBLIN GA
31021-2885
US

IV. Provider business mailing address

2400 BELLEVUE RD STE 21A
DUBLIN GA
31021-2890
US

V. Phone/Fax

Practice location:
  • Phone: 478-328-0281
  • Fax: 478-328-0438
Mailing address:
  • Phone: 478-328-0281
  • Fax: 478-328-0438

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 Code207NI0002X
TaxonomyClinical & Laboratory Dermatological Immunology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL J SHARKEY
Title or Position: OWNER
Credential: MD
Phone: 478-275-2694