Healthcare Provider Details

I. General information

NPI: 1114022167
Provider Name (Legal Business Name): AQUA DERMATOLOGY OF GEORGIA PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 09/16/2024
Certification Date: 09/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

835 COGBURN AVE NW SUITE 100
MARIETTA GA
30060-1031
US

IV. Provider business mailing address

835 COGBURN AVE NW SUITE 100
MARIETTA GA
30060-1031
US

V. Phone/Fax

Practice location:
  • Phone: 770-422-5557
  • Fax: 770-422-5456
Mailing address:
  • Phone: 770-422-5557
  • Fax: 770-422-5456

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. THEODORE SCHIFF
Title or Position: OWNER
Credential: MD
Phone: 770-422-5557