1104987262 NPI number — DR. DIANE SIMONE MCDERMOTT MEDICAL DOCTOR

Table of content: DR. DIANE SIMONE MCDERMOTT MEDICAL DOCTOR (NPI 1104987262)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104987262 NPI number — DR. DIANE SIMONE MCDERMOTT MEDICAL DOCTOR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCDERMOTT
Provider First Name:
DIANE
Provider Middle Name:
SIMONE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MEDICAL DOCTOR
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MCDERMOTT
Provider Other First Name:
DIANE
Provider Other Middle Name:
SIMONE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MEDICAL DOCTOR
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1104987262
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/05/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
824 WREN RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GOODLETTSVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37072-2312
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-851-8959
Provider Business Mailing Address Fax Number:
615-851-5949

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
824 WREN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GOODLETTSVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37072-2312
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
615-851-8959
Provider Business Practice Location Address Fax Number:
615-851-5949
Provider Enumeration Date:
12/13/2006

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: 207Q00000X , with the licence number:  MD25154 , 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: 205724681 . This is a "UNITED HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3094940 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: SSN . This is a "TRICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4147626 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 6271922 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3736131 . This is a "MEDICARE GROUP PRICING NO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 01041710 . This is a "AMERIGROUP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7078597 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: G20365 . This is a "HEALTHSPRINGS" identifier . This identifiers is of the category "OTHER".
  • Identifier: TN0102 . This is a "AMERICHOICE" identifier . This identifiers is of the category "OTHER".




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