Provider Demographics
NPI:1972644219
Name:PSYCHOLOGICAL MEDICINE CLINIC PLLC
Entity Type:Organization
Organization Name:PSYCHOLOGICAL MEDICINE CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD - PSYCHIATRIST
Authorized Official - Prefix:
Authorized Official - First Name:KRISHNA
Authorized Official - Middle Name:M
Authorized Official - Last Name:VERMA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:252-291-6200
Mailing Address - Street 1:1810 WESTWOOD AVE W
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:NC
Mailing Address - Zip Code:27893-2143
Mailing Address - Country:US
Mailing Address - Phone:252-291-6200
Mailing Address - Fax:252-291-2147
Practice Address - Street 1:1810 WESTWOOD AVE W
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893-2143
Practice Address - Country:US
Practice Address - Phone:252-291-6200
Practice Address - Fax:252-291-2147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2013-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2157403BOtherMEDICARE P-TAN
NC8985003Medicaid
NC8985003Medicaid