Provider Demographics
NPI:1407944168
Name:MARY K. MCDONALD MD PLLC
Entity Type:Organization
Organization Name:MARY K. MCDONALD MD PLLC
Other - Org Name:PAIN MEDICINE AND REHABILITATION
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:K
Authorized Official - Last Name:MCDONALD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-648-7667
Mailing Address - Street 1:PO BOX 22816
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37422-2816
Mailing Address - Country:US
Mailing Address - Phone:423-648-7667
Mailing Address - Fax:423-648-6279
Practice Address - Street 1:5211 HIGHWAY 153
Practice Address - Street 2:SUITE M
Practice Address - City:HIXSON
Practice Address - State:TN
Practice Address - Zip Code:37343-4956
Practice Address - Country:US
Practice Address - Phone:423-648-7667
Practice Address - Fax:423-648-6279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN285362081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4097642OtherBLUE CROSS AND BLUE SHIELD
P00194880OtherMEDICARE RAILROAD
G35110Medicare UPIN
TN4097642OtherBLUE CROSS AND BLUE SHIELD