Basic Information
| Provider Information | |||||||||
| NPI: | 1922343623 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UTMG DERMATOPATHOLOGY, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1407 UNION AVE STE 700 | ||||||||
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| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381043641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9018668360 | ||||||||
| FaxNumber: | 9013022360 | ||||||||
| Practice Location | |||||||||
| Address1: | 930 MADISON AVE STE 890 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381033413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9018668834 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2012 | ||||||||
| LastUpdateDate: | 04/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | RANDALL | ||||||||
| AuthorizedOfficialFirstName: | M. | ||||||||
| AuthorizedOfficialMiddleName: | BARRY | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9018668360 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 04/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | TN | Y | Laboratories | Clinical Medical Laboratory |
No ID Information.