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General NPI Number Information
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NPI Number | 1184005068
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Entity Type | Organization
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Legal Business Name | ADVANCED DERMATOLOGY OF GEORGIA, LLC
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Dates
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Enumeration Date | 06/16/2015
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Last Update Date | 01/22/2018
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Provider Practice Location Address
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Address Line | 401 W 4TH AVE
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City | ALBANY
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State | GA
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Zip | 31701-1915
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Country | US
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Telephone | 229-883-1130
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Fax | 229-883-1153
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Provider Business Mailing Address
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Address Line | 151 SOUTHHALL LN SUITE 300
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City | MAITLAND
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State | FL
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Zip | 32751-7176
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Country | US
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Telephone | 407-875-2080
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Fax | 407-650-3455
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Authorized Official
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Title or Position | DIRECTOR OF PROVIDER SERVICES
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Name | AMY DECLUE
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Credential |
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Telephone | 407-875-2080
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number |
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License Number State |
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