Healthcare Provider Details

I. General information

NPI: 1558339275
Provider Name (Legal Business Name): DERMATOLOGY SPECIALISTS OF AUGUSTA, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2006
Last Update Date: 01/13/2023
Certification Date: 01/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1203 TOWN PARK LN
EVANS GA
30809-3481
US

IV. Provider business mailing address

1306 CONCOURSE DR STE 201
LINTHICUM HEIGHTS MD
21090-1033
US

V. Phone/Fax

Practice location:
  • Phone: 706-650-7546
  • Fax: 706-922-9169
Mailing address:
  • Phone: 813-341-3259
  • Fax: 813-341-3259

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 Number049686
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: LISA BROOKS
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 727-547-0607