Provider Demographics
NPI:1295824415
Name:TRICITIES SKIN AND CANCER
Entity Type:Organization
Organization Name:TRICITIES SKIN AND CANCER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:STUFFLESTREET
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-722-0565
Mailing Address - Street 1:1009 N STATE OF FRANKLIN ACCESS ROAD
Mailing Address - Street 2:SUITE A
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-3693
Mailing Address - Country:US
Mailing Address - Phone:423-929-7546
Mailing Address - Fax:423-929-7968
Practice Address - Street 1:1009 N STATE OF FRANKLIN ACCESS ROAD SUITE A
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604
Practice Address - Country:US
Practice Address - Phone:423-929-7546
Practice Address - Fax:423-929-7968
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Single Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3720640Medicaid
TN3150220OtherBLUECROSS/BLUESHIELD
TNCH2549OtherRR MEDICARE
TN3720640Medicaid