Provider Demographics
NPI:1518163310
Name:PREMIERE DERMATOLOGY AND SURGERY, LLC
Entity type:Organization
Organization Name:PREMIERE DERMATOLOGY AND SURGERY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:BOUTTE
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:404-218-9671
Mailing Address - Street 1:4650 STONE MOUNTAIN HWY
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047
Mailing Address - Country:US
Mailing Address - Phone:678-344-2450
Mailing Address - Fax:678-344-2501
Practice Address - Street 1:4650 STONE MOUNTAIN HWY
Practice Address - Street 2:
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047
Practice Address - Country:US
Practice Address - Phone:678-344-2450
Practice Address - Fax:678-344-2501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-27
Last Update Date:2015-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA39318207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAG54474Medicare UPIN
GA07BBSHJMedicare ID - Type UnspecifiedDR BOUTTE