Provider Demographics
NPI:1770351041
Name:INTEGRATED SKIN INSTITUTE PLLC
Entity type:Organization
Organization Name:INTEGRATED SKIN INSTITUTE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:TEJASWI
Authorized Official - Middle Name:V
Authorized Official - Last Name:MUDIGONDA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:551-208-3090
Mailing Address - Street 1:1424 W BADDOUR PKWY STE G
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:TN
Mailing Address - Zip Code:37087-2685
Mailing Address - Country:US
Mailing Address - Phone:615-314-1699
Mailing Address - Fax:
Practice Address - Street 1:1424 W BADDOUR PKWY STE G
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:TN
Practice Address - Zip Code:37087-2685
Practice Address - Country:US
Practice Address - Phone:615-314-1699
Practice Address - Fax:615-622-8905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-18
Last Update Date:2024-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Multi-Specialty
No208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
No3336C0004XSuppliersPharmacyCompounding PharmacyGroup - Multi-Specialty