Basic Information
| Provider Information | |||||||||
| NPI: | 1356975106 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EAST TENNESSEE MEDICAL AND SURGICAL DERMATOLOGY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2898 BOONES CREEK RD STE 105 | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376154976 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232620112 | ||||||||
| FaxNumber: | 4234336060 | ||||||||
| Practice Location | |||||||||
| Address1: | 2898 BOONES CREEK RD STE 105 | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376154976 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232620112 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2020 | ||||||||
| LastUpdateDate: | 07/15/2020 | ||||||||
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| AuthorizedOfficialLastName: | LEICHT | ||||||||
| AuthorizedOfficialFirstName: | STUART | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 4232620112 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2500X | Y | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty |
No ID Information.