1114123056 NPI number — LAKEWAY DERMATOLOGY ASSOCIATES, PC

Table of content: (NPI 1114123056)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114123056 NPI number — LAKEWAY DERMATOLOGY ASSOCIATES, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKEWAY DERMATOLOGY ASSOCIATES, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114123056
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/26/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
400 E ECONOMY RD
Provider Second Line Business Mailing Address:
SUITE 8
Provider Business Mailing Address City Name:
MORRISTOWN
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37814-3388
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-587-4600
Provider Business Mailing Address Fax Number:
423-558-0010

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 E ECONOMY RD
Provider Second Line Business Practice Location Address:
SUITE 8
Provider Business Practice Location Address City Name:
MORRISTOWN
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37814-3388
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-587-4600
Provider Business Practice Location Address Fax Number:
423-581-1729
Provider Enumeration Date:
06/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BRIMHALL
Authorized Official First Name:
CONRAD
Authorized Official Middle Name:
L
Authorized Official Title or Position:
VP
Authorized Official Telephone Number:
859-276-1511

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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