Provider Demographics
NPI:1073825659
Name:DERMATOLOGY CLINIC OF JACKSON
Entity Type:Organization
Organization Name:DERMATOLOGY CLINIC OF JACKSON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:TEER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:731-424-1001
Mailing Address - Street 1:1320 UNION UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-3780
Mailing Address - Country:US
Mailing Address - Phone:731-422-7999
Mailing Address - Fax:731-422-4937
Practice Address - Street 1:1320 UNION UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-3780
Practice Address - Country:US
Practice Address - Phone:731-422-7999
Practice Address - Fax:731-422-4937
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-12
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN26042207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1521783Medicaid
TN1521783Medicaid