MEDICARE: PROSYNERGY DERMATOLOGY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207ND0101X	MOHS-Micrographic Surgery Physician
2	207N00000X	Dermatology Physician

General Provider Information

NPI Number	:	1205518875
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROSYNERGY DERMATOLOGY LLC

Provider Business Mailing Address
First Line	:	111 DAVIS RD
Second Line	:
City	:	MARTINEZ
State	:	GA
Zip	:	30907-2383
Country	:	US
Telephone Number	:	706-432-9285
Fax Number	:	706-432-9674

Provider Business Practice Location Address
First Line	:	111 DAVIS RD
Second Line	:
City	:	MARTINEZ
State	:	GA
Zip	:	30907-2383
Country	:	US
Telephone Number	:	706-432-9285
Fax Number	:	706-432-9674

Authorized Official
Title or Position	:	CEO AND PRESIDENT
Name	:	DR. STEPHEN MELVIN SQUIRES
Credential	:	MD
Telephone Number	:	706-432-9285

Provider Enumeration Date	:	08/03/2023
Last Update Date	:	08/03/2023

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