Provider Demographics
NPI:1033121157
Name:ADVANCED DERMATOLOGY OF EAST TENNESSEE, P.C.
Entity Type:Organization
Organization Name:ADVANCED DERMATOLOGY OF EAST TENNESSEE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LEWIS
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:SLAWSKY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:865-380-9300
Mailing Address - Street 1:615 SMITHVIEW DR
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37803-6100
Mailing Address - Country:US
Mailing Address - Phone:865-380-9300
Mailing Address - Fax:865-380-1558
Practice Address - Street 1:615 SMITHVIEW DR
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37803-6100
Practice Address - Country:US
Practice Address - Phone:865-380-9300
Practice Address - Fax:865-380-1558
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000026250207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3091975Medicaid
TN3144148OtherBCBS PROVIDER NUMBER
TN4619423OtherAETNA US HEALTHCARE
TNG03200Medicare UPIN
TN3091975Medicare ID - Type Unspecified