Healthcare Provider Details

I. General information

NPI: 1568780153
Provider Name (Legal Business Name): NICHOLAS DANIEL HYSMITH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2010
Last Update Date: 06/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 N DUNLAP ST G145 ULPS
MEMPHIS TN
38103
US

IV. Provider business mailing address

51 N DUNLAP ST G145
MEMPHIS MS
38654
US

V. Phone/Fax

Practice location:
  • Phone: 901-287-5437
  • Fax:
Mailing address:
  • Phone: 731-608-6160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number48992
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code2080P0208X
TaxonomyPediatric Infectious Diseases Physician
License Number48992
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: