Provider Demographics
NPI:1013911890
Name:BROCKMYRE, ANDREW (MD)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:BROCKMYRE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37662-0009
Mailing Address - Country:US
Mailing Address - Phone:423-857-2066
Mailing Address - Fax:423-857-2070
Practice Address - Street 1:240 MEDICAL PARK BLVD
Practice Address - Street 2:STE 3600
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-7346
Practice Address - Country:US
Practice Address - Phone:423-990-2400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2015-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD 29272207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3814287Medicaid
VA005644721Medicaid
VA005627605Medicaid
VA002978H81Medicare UPIN
VA005627605Medicaid
TN3814287Medicare PIN
G54795Medicare UPIN
TN3814287Medicaid
TN080107754Medicare PIN
TN103I0869169Medicare UPIN
VA005644721Medicaid