MEDICARE: ROY JOHN KERSEY PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	P501	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	4033879	OTHER	TN	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1245256254
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROY JOHN KERSEY PH.D.

Provider Business Mailing Address
First Line	:	3105 ESSARY DR
Second Line	:
City	:	KNOXVILLE
State	:	TN
Zip	:	37918-2409
Country	:	US
Telephone Number	:	865-687-8990
Fax Number	:	865-687-1190

Provider Business Practice Location Address
First Line	:	3105 ESSARY DR
Second Line	:
City	:	KNOXVILLE
State	:	TN
Zip	:	37918-2409
Country	:	US
Telephone Number	:	865-687-8990
Fax Number	:	865-687-1190

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/14/2006
Last Update Date	:	07/08/2007

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