Provider Demographics
NPI:1114123056
Name:LAKEWAY DERMATOLOGY ASSOCIATES, PC
Entity Type:Organization
Organization Name:LAKEWAY DERMATOLOGY ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:CONRAD
Authorized Official - Middle Name:L
Authorized Official - Last Name:BRIMHALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:859-276-1511
Mailing Address - Street 1:400 E ECONOMY RD
Mailing Address - Street 2:SUITE 8
Mailing Address - City:MORRISTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:37814-3388
Mailing Address - Country:US
Mailing Address - Phone:423-587-4600
Mailing Address - Fax:423-558-0010
Practice Address - Street 1:400 E ECONOMY RD
Practice Address - Street 2:SUITE 8
Practice Address - City:MORRISTOWN
Practice Address - State:TN
Practice Address - Zip Code:37814-3388
Practice Address - Country:US
Practice Address - Phone:423-587-4600
Practice Address - Fax:423-581-1729
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-26
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3715864Medicare PIN