Healthcare Provider Details

I. General information

NPI: 1881658243
Provider Name (Legal Business Name): ADULT & PEDIATRIC DERMATOLOGY OF TULLAHOMA PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2006
Last Update Date: 12/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 WILLIAM NORTHERN BLVD STE C
TULLAHOMA TN
37388
US

IV. Provider business mailing address

100 WILLIAM NORTHERN BLVD STE C
TULLAHOMA TN
37388
US

V. Phone/Fax

Practice location:
  • Phone: 931-455-7400
  • Fax: 931-455-6344
Mailing address:
  • Phone: 931-455-7400
  • Fax: 931-455-6344

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMD0000021099
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberMD0000021099
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License NumberMD0000021099
License Number StateTN

VIII. Authorized Official

Name: DR. KEN T TAKEGAMI
Title or Position: PRESIDENT
Credential: MD
Phone: 931-455-7400