NPIMap

Organization Active NPI

Tricities Skin and Cancer

  • Dermatology Physician
  • Johnson City, TN
National Provider Identifier
1295824415
Registry record updated Mar 17, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Dermatology PhysicianTaxonomy code 207N00000X
Legal business name
TRICITIES SKIN AND CANCER
Practice address
1009 N State of Franklin Access Road Suite a
Johnson City, TN 37604
Phone
(423) 929-7546
Fax
(423) 929-7968
NPI assigned
Oct 12, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 17, 2018

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Brenda Sue Stufflestreet
Title
Practice Administrator
Phone
(423) 722-0565

Specialties & licenses 4

Specialty (taxonomy)CodeLicenseStatePrimary
Dermatology PhysicianGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 207N00000X Primary
MOHS-Micrographic Surgery PhysicianGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 207ND0101X
Dermatopathology PhysicianGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 207ND0900X
Procedural Dermatology PhysicianGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 207NS0135X

Addresses

Primary practice location

1009 N State of Franklin Access Road Suite a
Johnson City, TN 37604

Mailing address

1009 N State of Franklin Access Road
Suite a
Johnson City, TN 37604-3693
Phone (423) 929-7546

Other practice location 1

1404 Tusculum Blvd Ste 1100
Greeneville, TN 37745-4395
Phone (423) 929-7546

Other identifiers 3

IdentifierTypeStateIssuer
3720640MedicaidTN
3150220OtherTNBLUECROSS/BLUESHIELD
CH2549OtherTNRR MEDICARE

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in TN

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040814000228 TN Part B Supplier - Clinic/Group Practice 8527031954 Receives reassigned benefits from 17 practitioners
Practice locations: Bristol, TN; Johnson City, TN

National Provider Directory

National Provider Directory

Locations

1009 N State of Franklin Rd
Johnson City, TN 37604
Phone (423) 722-0565

1009 N State of Franklin Rd
Ste A
Johnson City, TN 37604
Phone (423) 929-7546

1009 N State of Franklin Rd
#R
Johnson City, TN 37604
Phone (423) 929-7546

Practitioners & affiliated clinicians

Practitioners 17

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 17

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1160611200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1521244800000",
    "number": "1295824415",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1009 N STATE OF FRANKLIN ACCESS ROAD",
            "address_2": "SUITE A",
            "city": "JOHNSON CITY",
            "state": "TN",
            "postal_code": "376043693",
            "telephone_number": "423-929-7546",
            "fax_number": "423-929-7968"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1009 N STATE OF FRANKLIN ACCESS ROAD SUITE A",
            "city": "JOHNSON CITY",
            "state": "TN",
            "postal_code": "37604",
            "telephone_number": "423-929-7546",
            "fax_number": "423-929-7968"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "1404 Tusculum Blvd Ste 1100",
            "address_purpose": "LOCATION",
            "city": "Greeneville",
            "state": "TN",
            "postal_code": "377454395",
            "country_code": "US",
            "telephone_number": "423-929-7546",
            "fax_number": "423-929-7968",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "TRICITIES SKIN AND CANCER",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-10-12",
        "last_updated": "2018-03-17",
        "status": "A",
        "authorized_official_last_name": "STUFFLESTREET",
        "authorized_official_first_name": "BRENDA",
        "authorized_official_middle_name": "SUE",
        "authorized_official_title_or_position": "PRACTICE ADMINISTRATOR",
        "authorized_official_telephone_number": "423-722-0565"
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Dermatology",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "207ND0101X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Dermatology, MOHS-Micrographic Surgery",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207ND0900X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Dermatology, Dermatopathology",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207NS0135X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Dermatology, Procedural Dermatology",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "3720640",
            "state": "TN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUECROSS/BLUESHIELD",
            "identifier": "3150220",
            "state": "TN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RR MEDICARE",
            "identifier": "CH2549",
            "state": "TN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Johnson City, TN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 17, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.