MEDICARE: ADVANCED INTEGRATIVE MEDICINE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	225700000X	Massage Therapist
2	261QR0400X	Rehabilitation Clinic/Center
3	261QV0200X	VA Clinic/Center
4	207Q00000X	Family Medicine Physician
5	208VP0000X	Pain Medicine Physician
6	111N00000X	Chiropractor
7	171000000X	Military Health Care Provider
8	261QP3300X	Pain Clinic/Center

General Provider Information

NPI Number	:	1932983590
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADVANCED INTEGRATIVE MEDICINE

Provider Business Mailing Address
First Line	:	8204 LISA LN
Second Line	:
City	:	SMYRNA
State	:	TN
Zip	:	37167-3364
Country	:	US
Telephone Number	:	401-206-0715
Fax Number	:

Provider Business Practice Location Address
First Line	:	320 PHILLIPS ST FL 1
Second Line	:
City	:	NORTH KINGSTOWN
State	:	RI
Zip	:	02852-5166
Country	:	US
Telephone Number	:	401-206-0715
Fax Number	:

Authorized Official
Title or Position	:	COO
Name	:	DERRYL NOWAK
Credential	:
Telephone Number	:	401-206-0715

Provider Enumeration Date	:	08/23/2023
Last Update Date	:	08/23/2023

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