=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346719085
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 901 SKINMD PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/23/2018
-----------------------------------------------------
Last Update Date | 05/18/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 751 WALNUT KNOLL LANE SUITE 2
-----------------------------------------------------
City | CORDOVA
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38018-6301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-467-8632
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10020 IBERVILLE CV
-----------------------------------------------------
City | LAKELAND
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38002-7804
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-467-8632
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | DR. RADOSLAW BIENIEK
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 781-467-8632
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------