Provider Demographics
NPI:1043647142
Name:BRENTWOOD SKIN CLINIC PLLC
Entity Type:Organization
Organization Name:BRENTWOOD SKIN CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:AUSTIN
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:615-810-8730
Mailing Address - Street 1:5505 EDMONDSON PIKE
Mailing Address - Street 2:SUITE 10
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37211-5872
Mailing Address - Country:US
Mailing Address - Phone:615-810-8730
Mailing Address - Fax:615-810-8731
Practice Address - Street 1:5505 EDMONDSON PIKE
Practice Address - Street 2:SUITE 10
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37211-5872
Practice Address - Country:US
Practice Address - Phone:615-810-8730
Practice Address - Fax:615-810-8731
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-03
Last Update Date:2017-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN37546207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNPENDINGMedicaid
TNPENDINGMedicaid