Provider Demographics
NPI:1710187059
Name:SKIN CANCER AND SURGERY CENTER, PLC
Entity Type:Organization
Organization Name:SKIN CANCER AND SURGERY CENTER, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DERMATOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:R
Authorized Official - Last Name:MOODY
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:615-322-1221
Mailing Address - Street 1:1900 PATTERSON ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-2119
Mailing Address - Country:US
Mailing Address - Phone:615-322-1221
Mailing Address - Fax:615-322-5401
Practice Address - Street 1:1900 PATTERSON ST
Practice Address - Street 2:SUITE 201
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37203-2119
Practice Address - Country:US
Practice Address - Phone:615-322-1221
Practice Address - Fax:615-322-5401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-24
Last Update Date:2007-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN37502207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3884147Medicare PIN