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General NPI Number Information
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NPI Number | 1568032233
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Entity Type | Organization
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Legal Business Name | SUSONG DERMATOLOGY PLLC
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Dates
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Enumeration Date | 06/25/2021
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Last Update Date | 06/25/2021
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Provider Practice Location Address
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Address Line | 2158 NORTHGATE PARK LN STE 106
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City | CHATTANOOGA
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State | TN
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Zip | 37415-6911
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Country | US
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Telephone | 423-888-3376
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Fax | 423-870-1480
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Provider Business Mailing Address
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Address Line | 2158 NORTHGATE PARK LN STE 106
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City | CHATTANOOGA
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State | TN
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Zip | 37415-6911
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Country | US
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Telephone | 423-888-3376
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Fax | 423-870-1480
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Authorized Official
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Title or Position | CEO
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Name | DR. JASON SUSONG
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Credential | MD
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Telephone | 423-888-3376
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207ND0101X
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Taxonomy Name | MOHS-Micrographic Surgery Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number |
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License Number State |
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