Provider Demographics
NPI:1760673743
Name:KNOXVILLE INSTITUTE OF DERMATOLOGY PLLC
Entity Type:Organization
Organization Name:KNOXVILLE INSTITUTE OF DERMATOLOGY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ELIZEBETH
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:865-450-9361
Mailing Address - Street 1:DEPT 888213
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37995-8213
Mailing Address - Country:US
Mailing Address - Phone:865-670-6199
Mailing Address - Fax:865-670-6158
Practice Address - Street 1:6516 KINGSTON PIKE
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37919-4825
Practice Address - Country:US
Practice Address - Phone:865-450-9361
Practice Address - Fax:865-450-9362
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3370155Medicaid
TN3370155Medicare PIN
TNDG4812Medicare PIN