=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972644219
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PSYCHOLOGICAL MEDICINE CLINIC PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2007
-----------------------------------------------------
Last Update Date | 11/14/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1810 WESTWOOD AVE W
-----------------------------------------------------
City | WILSON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27893-2143
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-291-6200
-----------------------------------------------------
Fax | 252-291-2147
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1810 WESTWOOD AVE W
-----------------------------------------------------
City | WILSON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27893-2143
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-291-6200
-----------------------------------------------------
Fax | 252-291-2147
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MD - PSYCHIATRIST
-----------------------------------------------------
Name | KRISHNA M VERMA
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 252-291-6200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------