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General NPI Number Information
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NPI Number | 1366613663
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Entity Type | Organization
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Legal Business Name | PSIMED PA
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Dates
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Enumeration Date | 03/14/2008
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Last Update Date | 03/14/2008
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Provider Practice Location Address
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Address Line | 2511-D NEUDORF RD
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City | CLEMMONS
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State | NC
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Zip | 27012
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Country | US
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Telephone | 336-778-0506
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Fax | 336-778-0570
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Provider Business Mailing Address
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Address Line | PO BOX 1741
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City | CLEMMONS
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State | NC
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Zip | 27012
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Country | US
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Telephone | 336-778-0506
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Fax | 336-778-0570
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JASON MALCOLM CRANDELL
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Credential | MD
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Telephone | 336-918-4882
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 23500
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License Number State | NC
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