Provider Demographics
NPI:1720506231
Name:O'REILLY COMPREHENSIVE DERMATOLOGY, INC.
Entity type:Organization
Organization Name:O'REILLY COMPREHENSIVE DERMATOLOGY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT/SECRETARY
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:ZWALD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-273-4440
Mailing Address - Street 1:1421 WESSYNGTON ROAD
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30306
Mailing Address - Country:US
Mailing Address - Phone:404-273-4440
Mailing Address - Fax:
Practice Address - Street 1:755 MOUNT VERNON HWY.
Practice Address - Street 2:SUITE 330
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30228
Practice Address - Country:US
Practice Address - Phone:404-330-8445
Practice Address - Fax:404-330-8456
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-05
Last Update Date:2018-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA50418207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty