1932107125 NPI number — ANDREW HOWARD DEMICK PSYD

Table of content: BECCA R BUZANOSKI PMHNP (NPI 1720977572)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932107125 NPI number — ANDREW HOWARD DEMICK PSYD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEMICK
Provider First Name:
ANDREW
Provider Middle Name:
HOWARD
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PSYD
Provider Gender Code:
M

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:
1932107125
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6350 W ANDREW JOHNSON HWY DEPT 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TALBOTT
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37877-8605
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-355-3565
Provider Business Mailing Address Fax Number:
423-714-2355

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
501 ADESA BLVD STE A150
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LENOIR CITY
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37771-6719
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
865-986-8082
Provider Business Practice Location Address Fax Number:
865-986-5890
Provider Enumeration Date:
07/12/2005

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: 103TC0700X , with the licence number:  P2287 , 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: 3980929 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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