1316940182 NPI number — DR. JUDITH G TUDIVER PH.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316940182 NPI number — DR. JUDITH G TUDIVER PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TUDIVER
Provider First Name:
JUDITH
Provider Middle Name:
G
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1316940182
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3337 BONDWOOD CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JOHNSON CITY
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37604-8904
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-341-4752
Provider Business Mailing Address Fax Number:
423-283-0931

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
415 E UNAKA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JOHNSON CITY
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37601-4030
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-341-4752
Provider Business Practice Location Address Fax Number:
423-283-0931
Provider Enumeration Date:
05/24/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TB0200X , with the licence number:  P0000002479 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 540270000 . This is a "MAGELLAN MIS" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 229346 . This is a "COMPSYCH" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 4065358 . This is a "BS PIN-UNAKA ADDRESS" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 3982954 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4065358 . This is a "BC BS TN PIN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 7270161 . This is a "AETNA PIN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 010300860 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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