Provider Demographics
NPI:1043400088
Name:GEORGIA MOUNTAIN DERMATOLOGY, LLC
Entity type:Organization
Organization Name:GEORGIA MOUNTAIN DERMATOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CARLTON
Authorized Official - Middle Name:TRENT
Authorized Official - Last Name:FAULK
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:706-253-3376
Mailing Address - Street 1:150 INTERSTATE SOUTH DRIVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:JASPER
Mailing Address - State:GA
Mailing Address - Zip Code:30143
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:150 INTERSTATE SOUTH DRIVE
Practice Address - Street 2:SUITE 100
Practice Address - City:JASPER
Practice Address - State:GA
Practice Address - Zip Code:30143
Practice Address - Country:US
Practice Address - Phone:706-253-3376
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-26
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA033322207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAF55640Medicare UPIN