Provider Demographics
NPI:1114010741
Name:FAIRHURST DERMATOLOGY
Entity Type:Organization
Organization Name:FAIRHURST DERMATOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:VICTOR
Authorized Official - Last Name:FAIRHURST
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:615-870-1404
Mailing Address - Street 1:3040 BUSINESS PARK CIR
Mailing Address - Street 2:
Mailing Address - City:GOODLETTSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37072-3594
Mailing Address - Country:US
Mailing Address - Phone:615-870-1404
Mailing Address - Fax:615-870-1454
Practice Address - Street 1:3040 BUSINESS PARK CIR
Practice Address - Street 2:
Practice Address - City:GOODLETTSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37072-3594
Practice Address - Country:US
Practice Address - Phone:615-870-1404
Practice Address - Fax:615-870-1454
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2013-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN36190174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
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