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General NPI Number Information
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NPI Number | 1205026168
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Entity Type | Organization
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Legal Business Name | GEORGIA SKIN CANCER & AESTHEITIC DERMATOLOGY, LLC
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Dates
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Enumeration Date | 07/26/2007
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Last Update Date | 10/02/2019
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Provider Practice Location Address
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Address Line | 1180 RESURGENCE DR STE 100
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City | WATKINSVILLE
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State | GA
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Zip | 30677-7211
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Country | US
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Telephone | 706-543-5858
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Fax | 706-621-5804
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Provider Business Mailing Address
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Address Line | 1180 RESURGENCE DR STE 100
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City | WATKINSVILLE
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State | GA
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Zip | 30677-7211
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Country | US
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Telephone | 706-543-5858
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Fax | 706-621-5804
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Authorized Official
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Title or Position | OWNER
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Name | ROSS MARTIN CAMPBELL
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Credential | M.D.
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Telephone | 706-543-5858
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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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