Provider Demographics
NPI:1063736122
Name:KNOXVILLE DERMATOLOGY GROUP PC
Entity type:Organization
Organization Name:KNOXVILLE DERMATOLOGY GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TRES
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:L
Authorized Official - Last Name:MEYERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:865-690-9467
Mailing Address - Street 1:1928 ALCOA HWY
Mailing Address - Street 2:SUITE 209
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37920-1502
Mailing Address - Country:US
Mailing Address - Phone:865-690-9467
Mailing Address - Fax:865-342-5857
Practice Address - Street 1:1928 ALCOA HWY
Practice Address - Street 2:SUITE 209
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37920-1502
Practice Address - Country:US
Practice Address - Phone:865-690-9467
Practice Address - Fax:865-342-5857
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-18
Last Update Date:2010-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3376258Medicare PIN