Healthcare Provider Details

I. General information

NPI: 1447363346
Provider Name (Legal Business Name): GEORGIA DERMATOLOGY &SKIN CANCER CENTER, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1157 FORSYTH ST
MACON GA
31201-7452
US

IV. Provider business mailing address

PO BOX 6898
MACON GA
31208-6898
US

V. Phone/Fax

Practice location:
  • Phone: 478-328-1433
  • Fax: 478-922-7939
Mailing address:
  • Phone: 478-328-1433
  • Fax: 478-922-7939

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: BEVERLY B SANDERS
Title or Position: OWNER
Credential: MD
Phone: 478-328-1433