NPIMap

Organization Active NPI

Dermatology Specialists of Georgia, LLC

  • Dermatology Physician
  • Athens, GA
National Provider Identifier
1437298957
Registry record updated Sep 2, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Dermatology PhysicianTaxonomy code 207N00000X
License
18041 Issued in GA
Legal business name
DERMATOLOGY SPECIALISTS OF GEORGIA, LLC
Practice address
658 N Chase Street Unit 102
Athens, GA 30601
Phone
(877) 231-3376
Fax
(850) 522-8354
NPI assigned
Feb 5, 2007
Last updated
Sep 2, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 2, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Jon R Ward, MDNPI 1720039829
Title
MD/Owner
Phone
(850) 233-3376

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Dermatology Physician 207N00000X 18041 GA Primary

Addresses

Primary practice location

658 N Chase Street Unit 102
Athens, GA 30601

Mailing address

2505 Harrison Ave
Panama City, FL 32405-4464
Phone (877) 231-3376

Other identifiers 3

IdentifierTypeStateIssuer
000084961BMedicaidGA
10059273OtherGAAMERIGROUP
30926OtherGAWELLCARE

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in GA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040419001229 GA Part B Supplier - Clinic/Group Practice 5799770624 Receives reassigned benefits from 22 practitioners
Practice locations: Watkinsville, GA; Tucker, GA; Marietta, GA; Ellijay, GA; Athens, GA; Alpharetta, GA; Lagrange, GA

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
11D0261884Dermatology Specialists of Georgia LLC658 N Chase Street Suite 102, Athens, GA 30601ComplianceMay 31, 2027

National Provider Directory

National Provider Directory

Locations

2505 Harrison Ave
Panama City, FL 32405
Phone 85023333762619

11975 Morris Rd
Ste 310A
Alpharetta, GA 30005
Phone (678) 392-4433

728 Cobb St
Athens, GA 30606
Phone (706) 548-3019

1462 Montreal Rd
Ste 411
Tucker, GA 30084
Phone (404) 296-8000

Practitioners & affiliated clinicians

Practitioners 25

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 25

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1170633600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1662076800000",
    "number": "1437298957",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2505 HARRISON AVE",
            "city": "PANAMA CITY",
            "state": "FL",
            "postal_code": "324054464",
            "telephone_number": "877-231-3376",
            "fax_number": "850-522-8354"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "658 N CHASE STREET UNIT 102",
            "city": "ATHENS",
            "state": "GA",
            "postal_code": "30601",
            "telephone_number": "877-231-3376",
            "fax_number": "850-522-8354"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DERMATOLOGY SPECIALISTS OF GEORGIA, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-02-05",
        "last_updated": "2022-09-02",
        "certification_date": "2022-09-01",
        "status": "A",
        "authorized_official_last_name": "WARD",
        "authorized_official_first_name": "JON",
        "authorized_official_middle_name": "R",
        "authorized_official_title_or_position": "MD/OWNER",
        "authorized_official_telephone_number": "850-233-3376",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "",
            "desc": "Dermatology",
            "state": "GA",
            "license": "18041",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "000084961B",
            "state": "GA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "AMERIGROUP",
            "identifier": "10059273",
            "state": "GA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "WELLCARE",
            "identifier": "30926",
            "state": "GA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Athens, GA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 2, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.