Healthcare Provider Details

I. General information

NPI: 1891050407
Provider Name (Legal Business Name): EAST TENNESSEE DERMATOLOGY GROUP, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2012
Last Update Date: 08/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 ASSOCIATES BLVD
ALCOA TN
37701-1944
US

IV. Provider business mailing address

133 ASSOCIATES BLVD
ALCOA TN
37701-1944
US

V. Phone/Fax

Practice location:
  • Phone: 865-233-7351
  • Fax: 865-233-7352
Mailing address:
  • Phone: 865-233-7351
  • Fax: 865-233-7352

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMD0000035046
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberMD0000035046
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License NumberMD0000035046
License Number StateTN

VIII. Authorized Official

Name: ROBERT PAUL UNKEFER
Title or Position: PRESIDENT
Credential: M.D.
Phone: 865-233-7351