Provider Demographics
NPI:1003885989
Name:MCCUE, JACK D (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:D
Last Name:MCCUE
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 1:101 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:CA
Mailing Address - Zip Code:94930-1975
Mailing Address - Country:US
Mailing Address - Phone:209-727-4715
Mailing Address - Fax:
Practice Address - Street 1:REGIONAL MEDICAL CENTER AT MEMPHIS
Practice Address - Street 2:ADAMS AG#62
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38103
Practice Address - Country:US
Practice Address - Phone:901-545-6112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-14
Last Update Date:2008-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG85468207R00000X
TN44210207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
C66122Medicare UPIN