=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235135252
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GEORGIA DERMATOPATHOLOGY ASSOCIATES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/23/2005
-----------------------------------------------------
Last Update Date | 05/23/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1610 LAVISTA RD NE STE 4
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30329-4316
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-371-0077
-----------------------------------------------------
Fax | 404-371-1900
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 265
-----------------------------------------------------
City | EVANSVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47702-0265
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-471-1591
-----------------------------------------------------
Fax | 812-471-6650
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. MICHAEL SCOTT HOWARD IV
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 404-371-0077
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | 145104
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------