Healthcare Provider Details

I. General information

NPI: 1568032233
Provider Name (Legal Business Name): SUSONG DERMATOLOGY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2021
Last Update Date: 06/25/2021
Certification Date: 06/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2158 NORTHGATE PARK LN STE 106
CHATTANOOGA TN
37415-6911
US

IV. Provider business mailing address

2158 NORTHGATE PARK LN STE 106
CHATTANOOGA TN
37415-6911
US

V. Phone/Fax

Practice location:
  • Phone: 423-888-3376
  • Fax: 423-870-1480
Mailing address:
  • Phone: 423-888-3376
  • Fax: 423-870-1480

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JASON SUSONG
Title or Position: CEO
Credential: MD
Phone: 423-888-3376