Provider Demographics
NPI:1164404869
Name:MCCORMICK, PEGGY SUE (CRNA)
Entity Type:Individual
Prefix:
First Name:PEGGY
Middle Name:SUE
Last Name:MCCORMICK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:PEGGY
Other - Middle Name:SUE
Other - Last Name:TRUITT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 3849
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47803-0849
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:903-677-5586
Practice Address - Street 1:1421 N 7TH ST
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47807-1005
Practice Address - Country:US
Practice Address - Phone:812-232-7192
Practice Address - Fax:903-677-5586
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2024-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28168822A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000508470OtherBLUE CROSS/BLUE SHIELD
IN000000508470OtherBLUE CROSS/BLUE SHIELD
INP00395535Medicare PIN