Provider Demographics
NPI:1457751489
Name:DERMATOLOGY REALM AND FAMILY PRACTICE
Entity type:Organization
Organization Name:DERMATOLOGY REALM AND FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:W
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:901-362-7170
Mailing Address - Street 1:2120 MERCHANTS ROW STE 2
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-0806
Mailing Address - Country:US
Mailing Address - Phone:901-362-7170
Mailing Address - Fax:901-365-9712
Practice Address - Street 1:2120 MERCHANTS ROW STE 2
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-0806
Practice Address - Country:US
Practice Address - Phone:901-362-7170
Practice Address - Fax:901-365-9712
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-27
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD36947207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNMD36947OtherMEDICAL LICENSE