Basic Information
Provider Information | |||||||||
NPI: | 1861456287 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SYMED, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 55 HATCHETTS HILL RD | ||||||||
Address2: |   | ||||||||
City: | OLD LYME | ||||||||
State: | CT | ||||||||
PostalCode: | 063711534 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8003703651 | ||||||||
FaxNumber: | 8775157147 | ||||||||
Practice Location | |||||||||
Address1: | 3175 LENOX PARK BLVD | ||||||||
Address2: | SUITE 412 | ||||||||
City: | MEMPHIS | ||||||||
State: | TN | ||||||||
PostalCode: | 381154260 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9012732368 | ||||||||
FaxNumber: | 9012732351 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/13/2006 | ||||||||
LastUpdateDate: | 07/11/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KING | ||||||||
AuthorizedOfficialFirstName: | MELISSA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR, CREDENTIALING ENROLLMENT | ||||||||
AuthorizedOfficialTelephone: | 8003703651 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LG0600X | R32353 | AR | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
No ID Information.