1780948950 NPI number — GARY A. WISHART, PSY.D., PLLC

Table of content: (NPI 1780948950)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780948950 NPI number — GARY A. WISHART, PSY.D., PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GARY A. WISHART, PSY.D., PLLC
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:
1780948950
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/02/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
601 VOLUNTEER PKWY
Provider Second Line Business Mailing Address:
SUITE G
Provider Business Mailing Address City Name:
BRISTOL
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37620-3653
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-652-2212
Provider Business Mailing Address Fax Number:
423-652-2212

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
601 VOLUNTEER PKWY
Provider Second Line Business Practice Location Address:
SUITE G
Provider Business Practice Location Address City Name:
BRISTOL
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37620-3653
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-652-2212
Provider Business Practice Location Address Fax Number:
423-652-2212
Provider Enumeration Date:
07/02/2012

Additional Information

Authorized Official

Authorized Official Last Name:
WISHART
Authorized Official First Name:
GARY
Authorized Official Middle Name:
AUSTIN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
423-652-2212

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  P0000001915 , 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: 0004551019 . This is a "AETNA" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 00610001154 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 104229 . This is a "VALUE OPTIONS" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 0181971 . This is a "BLUE CROSS/BLUE SHIELD" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 1982775821 . This is a "ALL INSURANCE CARRIERS AND MEDICARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 085256 . This is a "ANTHEM OF VIRGINIA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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