Organization
ADULT & PEDIATRIC DERMATOLOGY OF TULLAHOMA PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. KEN T TAKEGAMI MD (PRESIDENT)
(931) 455-7400
Entity
Organization
Contact information
Practice address
100 WILLIAM NORTHERN BLVD, STE C, TULLAHOMA, TN 37388
(931) 455-7400
(931) 455-6344
Mailing address
100 WILLIAM NORTHERN BLVD, STE C, TULLAHOMA, TN 37388
(931) 455-7400
(931) 455-6344
Taxonomy
Speciality
Code
Description
License number
State
207N00000X
Dermatology Physician
Primary
MD0000021099
TN
207ND0101X
MOHS-Micrographic Surgery Physician
MD0000021099
TN
207ND0900X
Dermatopathology Physician
MD0000021099
TN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
3373903
—
TN
Enumeration date
04/13/2006
Last updated
12/03/2009
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