Organization
FAIRHURST DERMATOLOGY
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. MARK VICTOR FAIRHURST MD (PRESIDENT/OWNER)
(615) 870-1404
Entity
Organization
Contact information
Practice address
3040 BUSINESS PARK CIR, GOODLETTSVILLE, TN 37072-3594
(615) 870-1404
(615) 870-1454
Mailing address
3040 BUSINESS PARK CIR, GOODLETTSVILLE, TN 37072-3594
(615) 870-1404
(615) 870-1454
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
36190
TN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
3714159
—
TN
01
—
4053381
TENNCARE SELECT PROV NUMB
TN
01
—
4281928
AETNA PROVIDER NUMBER
TN
01
—
50554854
TRICARE PROVIDER NUMBER
TN
01
—
F27966
HEALTHSPRING PROVIDER NUM
TN
01
—
P00010292
RAILROAD MEDICAID PROV NU
TN
Enumeration date
10/02/2006
Last updated
03/19/2013
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