Premiere Dermatology and Surgery, LLC

Primary specialty

Dermatology PhysicianTaxonomy code 207N00000X

License

39318 Issued in GA

Legal business name

PREMIERE DERMATOLOGY AND SURGERY, LLC

Practice address

4650 Stone Mountain Hwy
Lilburn, GA 30047

Phone

(678) 344-2450

Fax

(678) 344-2501

NPI assigned

Jun 27, 2007

Last updated

Jun 17, 2015By the provider in NPPES

Organization subpart

No

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

Authorized official

Name

Paul Boutte Sr.

Title

Practice Manager

Phone

(404) 218-9671

Specialties & licenses 1

Addresses

Other names 1

• Premere Dermatology and Surgery, LLC Former legal business name

Locations

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

{
    "created_epoch": "1182902400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1434499200000",
    "number": "1518163310",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4650 STONE MOUNTAIN HWY",
            "city": "LILBURN",
            "state": "GA",
            "postal_code": "30047",
            "telephone_number": "678-344-2450",
            "fax_number": "678-344-2501"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4650 STONE MOUNTAIN HWY",
            "city": "LILBURN",
            "state": "GA",
            "postal_code": "30047",
            "telephone_number": "678-344-2450",
            "fax_number": "678-344-2501"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PREMIERE DERMATOLOGY AND SURGERY, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-06-27",
        "last_updated": "2015-06-17",
        "status": "A",
        "authorized_official_last_name": "BOUTTE",
        "authorized_official_first_name": "PAUL",
        "authorized_official_title_or_position": "PRACTICE MANAGER",
        "authorized_official_telephone_number": "404-218-9671",
        "authorized_official_name_suffix": "Sr."
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "",
            "desc": "Dermatology",
            "state": "GA",
            "license": "39318",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Premere Dermatology and Surgery, LLC",
            "code": "4",
            "type": "Former Legal Business Name"
        }
    ]
}

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• Dermatology Physician in Lilburn, GA
• Providers in Lilburn, GA by specialty
• Dermatology Physician in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 17, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.