Healthcare Provider Details

I. General information

NPI: 1871768846
Provider Name (Legal Business Name): DERMATOLOGY AND DERMATOLOGIC SURGERY LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2008
Last Update Date: 02/22/2024
Certification Date: 02/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 HEALTH PARK DR STE 470
BRENTWOOD TN
37027-5721
US

IV. Provider business mailing address

1001 HEALTH PARK DR STE 470
BRENTWOOD TN
37027-5721
US

V. Phone/Fax

Practice location:
  • Phone: 630-302-3677
  • Fax: 630-302-3677
Mailing address:
  • Phone: 630-302-3677
  • Fax: 630-302-3677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number2086A0122X
License Number StateIL

VIII. Authorized Official

Name: JEFFREY BERTI
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 630-302-3677