Basic Information
| Provider Information | |||||||||
| NPI: | 1275828717 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DERRICK | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | IAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1272 GARRISON DR | ||||||||
| Address2: | |||||||||
| City: | MURFREESBORO | ||||||||
| State: | TN | ||||||||
| PostalCode: | 371292598 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6158934480 | ||||||||
| FaxNumber: | 6158956212 | ||||||||
| Practice Location | |||||||||
| Address1: | 1272 GARRISON DR | ||||||||
| Address2: | |||||||||
| City: | MURFREESBORO | ||||||||
| State: | TN | ||||||||
| PostalCode: | 371292598 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6158934480 | ||||||||
| FaxNumber: | 6158956212 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2011 | ||||||||
| LastUpdateDate: | 07/25/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0201X | 04-40205 | KS | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Allergy/Immunology | 2080P0201X | 2017023519 | MO | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Allergy/Immunology | 2080P0201X | MD65969 | TN | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Allergy/Immunology |
No ID Information.