Provider Demographics
NPI:1942703848
Name:KNOXVILLE CENTER FOR DERMATOLOGY AND PLASTIC SURGERY, PL
Entity Type:Organization
Organization Name:KNOXVILLE CENTER FOR DERMATOLOGY AND PLASTIC SURGERY, PL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:P
Authorized Official - Last Name:FOWLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:865-470-4124
Mailing Address - Street 1:PO BOX 11268
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37939-1268
Mailing Address - Country:US
Mailing Address - Phone:865-470-4127
Mailing Address - Fax:833-790-3693
Practice Address - Street 1:9430 PARK WEST BLVD STE 240
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37923
Practice Address - Country:US
Practice Address - Phone:865-470-4127
Practice Address - Fax:833-790-3693
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-16
Last Update Date:2018-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ035060Medicaid