Provider Demographics
NPI:1447343694
Name:CHATTANOOGA SKIN & CANCER CLINIC
Entity type:Organization
Organization Name:CHATTANOOGA SKIN & CANCER CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:BANKS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-899-2700
Mailing Address - Street 1:6141 SHALLOWFORD ROAD
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421
Mailing Address - Country:US
Mailing Address - Phone:423-899-2700
Mailing Address - Fax:423-899-2703
Practice Address - Street 1:6141 SHALLOWFORD ROAD
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421
Practice Address - Country:US
Practice Address - Phone:423-899-2700
Practice Address - Fax:423-899-2700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3388761Medicare PIN