Provider Demographics
NPI:1770641268
Name:DERMATOLOGY SPECIALISTS PLLC
Entity Type:Organization
Organization Name:DERMATOLOGY SPECIALISTS PLLC
Other - Org Name:GREATER KNOXVILLE DERMATOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:KANG-ROTONDO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:865-524-7107
Mailing Address - Street 1:7730 DANNAHER DR
Mailing Address - Street 2:
Mailing Address - City:POWELL
Mailing Address - State:TN
Mailing Address - Zip Code:37849-4039
Mailing Address - Country:US
Mailing Address - Phone:865-524-7107
Mailing Address - Fax:865-524-3709
Practice Address - Street 1:7730 DANNAHER DR
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:TN
Practice Address - Zip Code:37849-4039
Practice Address - Country:US
Practice Address - Phone:865-524-7107
Practice Address - Fax:865-524-3709
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2019-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3722491Medicaid
TN3722491Medicaid