Healthcare Provider Details

I. General information

NPI: 1275828717
Provider Name (Legal Business Name): MICHAEL IAN DERRICK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2011
Last Update Date: 07/25/2022
Certification Date: 07/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1272 GARRISON DR
MURFREESBORO TN
37129-2598
US

IV. Provider business mailing address

1272 GARRISON DR
MURFREESBORO TN
37129-2598
US

V. Phone/Fax

Practice location:
  • Phone: 615-893-4480
  • Fax: 615-895-6212
Mailing address:
  • Phone: 615-893-4480
  • Fax: 615-895-6212

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0201X
TaxonomyPediatric Allergy/Immunology Physician
License Number04-40205
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code2080P0201X
TaxonomyPediatric Allergy/Immunology Physician
License Number2017023519
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code2080P0201X
TaxonomyPediatric Allergy/Immunology Physician
License NumberMD65969
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: