Provider Demographics
NPI:1669662516
Name:BRISTOL DERMATOLOGY, PLLC
Entity Type:Organization
Organization Name:BRISTOL DERMATOLOGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:WARRICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:803-546-7522
Mailing Address - Street 1:350 BLOUNTVILLE HWY
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BRISTOL
Mailing Address - State:TN
Mailing Address - Zip Code:37620-0213
Mailing Address - Country:US
Mailing Address - Phone:423-217-1337
Mailing Address - Fax:423-217-1249
Practice Address - Street 1:350 BLOUNTVILLE HWY
Practice Address - Street 2:SUITE 201
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-0213
Practice Address - Country:US
Practice Address - Phone:423-217-1337
Practice Address - Fax:423-217-1249
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-26
Last Update Date:2009-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN40472207N00000X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCB91769Medicare UPIN