1407944168 NPI number — MARY K. MCDONALD MD PLLC

Table of content: (NPI 1407944168)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407944168 NPI number — MARY K. MCDONALD MD PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARY K. MCDONALD MD PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PAIN MEDICINE AND REHABILITATION
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407944168
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/25/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 22816
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHATTANOOGA
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37422-2816
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-648-7667
Provider Business Mailing Address Fax Number:
423-648-6279

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5211 HIGHWAY 153
Provider Second Line Business Practice Location Address:
SUITE M
Provider Business Practice Location Address City Name:
HIXSON
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37343-4956
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-648-7667
Provider Business Practice Location Address Fax Number:
423-648-6279
Provider Enumeration Date:
10/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MCDONALD
Authorized Official First Name:
MARY
Authorized Official Middle Name:
K
Authorized Official Title or Position:
DIRECTOR PHYSICIAN
Authorized Official Telephone Number:
423-648-7667

Provider Taxonomy Codes

  • Taxonomy code: 2081P2900X , with the licence number:  28536 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4097642 . This is a "BLUE CROSS AND BLUE SHIELD" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: P00194880 . This is a "MEDICARE RAILROAD" identifier . This identifiers is of the category "OTHER".




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