Provider Demographics
NPI:1104987262
Name:MCDERMOTT, DIANE SIMONE (MEDICAL DOCTOR)
Entity type:Individual
Prefix:DR
First Name:DIANE
Middle Name:SIMONE
Last Name:MCDERMOTT
Suffix:
Gender:F
Credentials:MEDICAL DOCTOR
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:SIMONE
Other - Last Name:MCDERMOTT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MEDICAL DOCTOR
Mailing Address - Street 1:824 WREN RD
Mailing Address - Street 2:
Mailing Address - City:GOODLETTSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37072-2312
Mailing Address - Country:US
Mailing Address - Phone:615-851-8959
Mailing Address - Fax:615-851-5949
Practice Address - Street 1:824 WREN RD
Practice Address - Street 2:
Practice Address - City:GOODLETTSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37072-2312
Practice Address - Country:US
Practice Address - Phone:615-851-8959
Practice Address - Fax:615-851-5949
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2008-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD25154207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
205724681OtherUNITED HEALTHCARE
TN3094940Medicaid
SSNOtherTRICARE
4147626OtherBCBS
6271922OtherCIGNA
3736131OtherMEDICARE GROUP PRICING NO
01041710OtherAMERIGROUP
7078597OtherAETNA
G20365OtherHEALTHSPRINGS
TN0102OtherAMERICHOICE
TN0102OtherAMERICHOICE
205724681OtherHEALING PLACE FMC EIN
TN0102OtherAMERICHOICE