Healthcare Provider Details

I. General information

NPI: 1669662516
Provider Name (Legal Business Name): BRISTOL DERMATOLOGY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2007
Last Update Date: 09/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 BLOUNTVILLE HWY SUITE 201
BRISTOL TN
37620-0213
US

IV. Provider business mailing address

350 BLOUNTVILLE HWY SUITE 201
BRISTOL TN
37620-0213
US

V. Phone/Fax

Practice location:
  • Phone: 423-217-1337
  • Fax: 423-217-1249
Mailing address:
  • Phone: 423-217-1337
  • Fax: 423-217-1249

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number40472
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number40472
License Number StateTN

VIII. Authorized Official

Name: DR. KENNETH RAY WARRICK
Title or Position: PRESIDENT
Credential: M.D.
Phone: 803-546-7522