Provider Demographics
NPI:1013195106
Name:DOUGLAS DYCUS
Entity Type:Organization
Organization Name:DOUGLAS DYCUS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:DYCUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:931-268-3224
Mailing Address - Street 1:PO BOX 247
Mailing Address - Street 2:
Mailing Address - City:GAINESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:38562-0247
Mailing Address - Country:US
Mailing Address - Phone:931-268-3224
Mailing Address - Fax:931-268-3228
Practice Address - Street 1:3698 S GRUNDY QUARLES HWY
Practice Address - Street 2:
Practice Address - City:GAINESBORO
Practice Address - State:TN
Practice Address - Zip Code:38562-5950
Practice Address - Country:US
Practice Address - Phone:931-268-3224
Practice Address - Fax:931-268-3228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-31
Last Update Date:2008-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD020847207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3371574Medicaid
TN3371574Medicare PIN