Provider Demographics
NPI:1093151045
Name:HIGHLANDS DERMATOLOGY AND SURGICAL ASSOCIATES
Entity Type:Organization
Organization Name:HIGHLANDS DERMATOLOGY AND SURGICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:S
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:931-520-1414
Mailing Address - Street 1:PO BOX 1210
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38503-1210
Mailing Address - Country:US
Mailing Address - Phone:931-520-1414
Mailing Address - Fax:931-520-1246
Practice Address - Street 1:112 N WALNUT AVE
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-2554
Practice Address - Country:US
Practice Address - Phone:931-520-1414
Practice Address - Fax:931-520-1246
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-17
Last Update Date:2013-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN18375174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN370850Medicare PIN