1962460998 NPI number — MR. MICHAEL C MCCONNELL CRNA

Table of content: MR. MICHAEL C MCCONNELL CRNA (NPI 1962460998)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962460998 NPI number — MR. MICHAEL C MCCONNELL CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCCONNELL
Provider First Name:
MICHAEL
Provider Middle Name:
C
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1962460998
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/09/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1407 UNION AVE
Provider Second Line Business Mailing Address:
SUITE 640
Provider Business Mailing Address City Name:
MEMPHIS
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38104-3627
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-866-8360
Provider Business Mailing Address Fax Number:
901-302-2360

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1407 UNION AVE
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
MEMPHIS
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38104-3600
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-866-8813
Provider Business Practice Location Address Fax Number:
901-302-2120
Provider Enumeration Date:
05/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  9302 , 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: 4010460 . This is a "BLUE CROSS W/MAA" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 136280701 . This is a "MEDICAID W/MAA" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 3607664 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 98469 . This is a "BLUE CROSS W/MAA" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 0116747 . This is a "MEDICAID W/MAA" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 430056979 . This is a "RAILROAD MEDICARE W/MAA" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 915066112 . This is a "MEDICAID W/MAA" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 3607663 . This is a "MEDICARE W/MAA" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 3607660 . This is a "MEDICAID W/MAA" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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