Basic Information
| Provider Information | |||||||||
| NPI: | 1124008636 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AFFILIATED DERMATOLOGY, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4300 W MAIN ST | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | DOTHAN | ||||||||
| State: | AL | ||||||||
| PostalCode: | 363051054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3347939564 | ||||||||
| FaxNumber: | 3346718907 | ||||||||
| Practice Location | |||||||||
| Address1: | 4300 W MAIN ST | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | DOTHAN | ||||||||
| State: | AL | ||||||||
| PostalCode: | 363051054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3347939564 | ||||||||
| FaxNumber: | 3346718907 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | SALLAS | ||||||||
| AuthorizedOfficialFirstName: | LOIS | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 3347939564 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | 207ND0101X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | MOHS-Micrographic Surgery | 207NS0135X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | Procedural Dermatology |
No ID Information.