MEDICARE: DR. JUDITH G TUDIVER 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	103TB0200X	Cognitive & Behavioral Psychologist	P0000002479	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	540270000	OTHER	TN	MAGELLAN MIS
2	229346	OTHER	TN	COMPSYCH
3	4065358	OTHER	TN	BS PIN-UNAKA ADDRESS
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	4065358	OTHER	TN	BC BS TN PIN
6	7270161	OTHER	TN	AETNA PIN
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1316940182
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JUDITH G TUDIVER PH.D.

Provider Business Mailing Address
First Line	:	3337 BONDWOOD CIR
Second Line	:
City	:	JOHNSON CITY
State	:	TN
Zip	:	37604-8904
Country	:	US
Telephone Number	:	423-341-4752
Fax Number	:	423-283-0931

Provider Business Practice Location Address
First Line	:	415 E UNAKA AVE
Second Line	:
City	:	JOHNSON CITY
State	:	TN
Zip	:	37601-4030
Country	:	US
Telephone Number	:	423-341-4752
Fax Number	:	423-283-0931

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

Provider Enumeration Date	:	05/24/2005
Last Update Date	:	07/09/2007

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