Basic Information
| Provider Information | |||||||||
| NPI: | 1295721512 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ALBANY DERMATOLOGY CLINIC, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 151 SOUTHHALL LANE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | MAITLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327517172 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4078752080 | ||||||||
| FaxNumber: | 4076503455 | ||||||||
| Practice Location | |||||||||
| Address1: | 2709 MEREDYTH DR | ||||||||
| Address2: | SUITE 340 | ||||||||
| City: | ALBANY | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317070222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2298831130 | ||||||||
| FaxNumber: | 2298831153 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2005 | ||||||||
| LastUpdateDate: | 04/12/2016 | ||||||||
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| AuthorizedOfficialLastName: | GREENFIELD | ||||||||
| AuthorizedOfficialFirstName: | MELINDA | ||||||||
| AuthorizedOfficialMiddleName: | F. | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 4078752080 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 049451 | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | CB2415 | 01 | GA | MEDICARE RAILROAD GROUP # | OTHER | 300021798A | 05 | GA | MEDICAID | GRP1577 | 01 | GA | MEDICARE SECONDARY GRP # | OTHER |