MEDICARE: SOUTH GEORGIA DERMATOLOGY, 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	044059	GA

General Provider Information

NPI Number	:	1770645228
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH GEORGIA DERMATOLOGY, PC

Provider Business Mailing Address
First Line	:	802 18TH ST E
Second Line	:
City	:	TIFTON
State	:	GA
Zip	:	31794-3661
Country	:	US
Telephone Number	:	229-386-9333
Fax Number	:	229-386-1666

Provider Business Practice Location Address
First Line	:	802 18TH ST E
Second Line	:
City	:	TIFTON
State	:	GA
Zip	:	31794-3661
Country	:	US
Telephone Number	:	229-386-9333
Fax Number	:	229-386-1666

Authorized Official
Title or Position	:	PRACTICE MANAGER
Name	:	KRISTYN ELIZABETH RENFROE
Credential	:
Telephone Number	:	229-386-9333

Provider Enumeration Date	:	12/14/2006
Last Update Date	:	08/22/2020

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