Provider Demographics
NPI:1750059622
Name:CHATTANOOGA DERMATOLOGY PLLC
Entity Type:Organization
Organization Name:CHATTANOOGA DERMATOLOGY PLLC
Other - Org Name:CHATTANOOGA DERMATOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:SUSONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-888-3376
Mailing Address - Street 1:2158 NORTHGATE PARK LN STE 106
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37415-6911
Mailing Address - Country:US
Mailing Address - Phone:423-888-3376
Mailing Address - Fax:423-870-1480
Practice Address - Street 1:2158 NORTHGATE PARK LN STE 106
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37415-6911
Practice Address - Country:US
Practice Address - Phone:423-888-3376
Practice Address - Fax:423-870-1480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-03
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Multi-Specialty