Provider Demographics
NPI:1730244872
Name:DERMATOLOGY AFFILIATES, LLC
Entity type:Organization
Organization Name:DERMATOLOGY AFFILIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:VIRGINIA
Authorized Official - Middle Name:RUTLEDGE
Authorized Official - Last Name:FORNEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-816-7900
Mailing Address - Street 1:PO BOX 52226
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30355-0226
Mailing Address - Country:US
Mailing Address - Phone:404-816-7900
Mailing Address - Fax:404-816-7929
Practice Address - Street 1:3131 MAPLE DR NE
Practice Address - Street 2:SUITE 102
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30305
Practice Address - Country:US
Practice Address - Phone:404-816-7900
Practice Address - Fax:404-816-7929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA044218174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAH20976Medicare UPIN