Basic Information
| Provider Information | |||||||||
| NPI: | 1518096601 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SYMED, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 55 HATCHETTS HILL RD | ||||||||
| Address2: | |||||||||
| City: | OLD LYME | ||||||||
| State: | CT | ||||||||
| PostalCode: | 063711534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003703651 | ||||||||
| FaxNumber: | 8775157147 | ||||||||
| Practice Location | |||||||||
| Address1: | 3150 LENOX PARK BLVD | ||||||||
| Address2: | SUITE 214 | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381154299 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9012732368 | ||||||||
| FaxNumber: | 9012732351 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2007 | ||||||||
| LastUpdateDate: | 07/11/2017 | ||||||||
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| AuthorizedOfficialLastName: | KING | ||||||||
| AuthorizedOfficialFirstName: | MELISSA | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR, CREDENTIALING ENROLLMENT | ||||||||
| AuthorizedOfficialTelephone: | 8003703651 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 3377956 | 05 | TN | MEDICAID |