Healthcare Provider Details

I. General information

NPI: 1043971575
Provider Name (Legal Business Name): FOUR BRIDGES DERMATOLOGY AND COSMETICS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2022
Last Update Date: 03/31/2022
Certification Date: 03/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1247 RIVERFRONT PKWY
CHATTANOOGA TN
37402-2108
US

IV. Provider business mailing address

1247 RIVERFRONT PKWY
CHATTANOOGA TN
37402-2108
US

V. Phone/Fax

Practice location:
  • Phone: 423-521-4232
  • Fax: 423-521-4235
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LAURA CLEARY
Title or Position: PARTNER
Credential: MD
Phone: 423-521-4232