Healthcare Provider Details

I. General information

NPI: 1366613663
Provider Name (Legal Business Name): PSIMED PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2008
Last Update Date: 03/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2511-D NEUDORF RD
CLEMMONS NC
27012
US

IV. Provider business mailing address

PO BOX 1741
CLEMMONS NC
27012
US

V. Phone/Fax

Practice location:
  • Phone: 336-778-0506
  • Fax: 336-778-0570
Mailing address:
  • Phone: 336-778-0506
  • Fax: 336-778-0570

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number23500
License Number StateNC

VIII. Authorized Official

Name: DR. JASON MALCOLM CRANDELL
Title or Position: PRESIDENT
Credential: MD
Phone: 336-918-4882