1053650200 NPI number — ADULT AND GERIATRIC PSYCHIATRY SERVICE

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 1053650200 NPI number — ADULT AND GERIATRIC PSYCHIATRY SERVICE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADULT AND GERIATRIC PSYCHIATRY SERVICE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1053650200
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/07/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 MED TECH PKWY STE 407
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:
37604-4000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-283-8801
Provider Business Mailing Address Fax Number:
423-282-4533

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1618 STRAWBERRY LN
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:
37604-7700
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-677-6787
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/07/2013

Additional Information

Authorized Official

Authorized Official Last Name:
BENDFELDT
Authorized Official First Name:
FERNANDO
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
423-283-8801

Provider Taxonomy Codes

  • Taxonomy code: 2084P0805X , with the licence number:  MD19195 , 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)





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