MEDICARE: GEORGIA DERMATOLOGY &SKIN CANCER CENTER, PC

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	207N00000X	Dermatology Physician

General Provider Information

NPI Number	:	1447363346
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GEORGIA DERMATOLOGY &SKIN CANCER CENTER, PC

Provider Business Mailing Address
First Line	:	PO BOX 6898
Second Line	:
City	:	MACON
State	:	GA
Zip	:	31208-6898
Country	:	US
Telephone Number	:	478-328-1433
Fax Number	:	478-922-7939

Provider Business Practice Location Address
First Line	:	1157 FORSYTH ST
Second Line	:
City	:	MACON
State	:	GA
Zip	:	31201-7452
Country	:	US
Telephone Number	:	478-328-1433
Fax Number	:	478-922-7939

Authorized Official
Title or Position	:	OWNER
Name	:	BEVERLY B SANDERS
Credential	:	MD
Telephone Number	:	478-328-1433

Provider Enumeration Date	:	08/16/2006
Last Update Date	:	08/22/2020

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