1407944168 NPI number — MARY K. MCDONALD MD PLLC

Table of Contents

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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