Basic Information
| Provider Information | |||||||||
| NPI: | 1568663334 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PERIMETER DERMATOLOGY, PC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GREGORY J COX MD | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5505 PEACHTREE DUNWOODY RD NE | ||||||||
| Address2: | SUITE 412 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303421705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4044599177 | ||||||||
| FaxNumber: | 4043890400 | ||||||||
| Practice Location | |||||||||
| Address1: | 5505 PEACHTREE DUNWOODY RD NE | ||||||||
| Address2: | SUITE 412 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303421705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4044599177 | ||||||||
| FaxNumber: | 4043890400 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2007 | ||||||||
| LastUpdateDate: | 02/10/2009 | ||||||||
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| AuthorizedOfficialLastName: | SULLIVAN | ||||||||
| AuthorizedOfficialFirstName: | LYNNE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4044599177 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 026089 | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 000361974C | 05 | GA | MEDICAID |