Organization
TRICITIES SKIN AND CANCER
Active
Organization subpart
No
Provider details
NPI number
Authorized official
BRENDA SUE STUFFLESTREET (PRACTICE ADMINISTRATOR)
(423) 722-0565
Entity
Organization
Contact information
Practice address
1009 N STATE OF FRANKLIN ACCESS ROAD SUITE A, JOHNSON CITY, TN 37604
(423) 929-7546
(423) 929-7968
Mailing address
1009 N STATE OF FRANKLIN ACCESS ROAD, SUITE A, JOHNSON CITY, TN 37604-3693
(423) 929-7546
(423) 929-7968
Taxonomy
Speciality
Code
Description
License number
State
207N00000X
Dermatology Physician
Primary
—
—
207ND0101X
MOHS-Micrographic Surgery Physician
—
—
207ND0900X
Dermatopathology Physician
—
—
207NS0135X
Procedural Dermatology Physician
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
3150220
BLUECROSS/BLUESHIELD
TN
05
—
3720640
—
TN
01
—
CH2549
RR MEDICARE
TN
Enumeration date
10/12/2006
Last updated
03/17/2018
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