Provider Demographics
NPI:1568693133
Name:MCCORMICK, MARY RUSSELL (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:RUSSELL
Last Name:MCCORMICK
Suffix:
Gender:F
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:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37662-0009
Mailing Address - Country:US
Mailing Address - Phone:423-857-2093
Mailing Address - Fax:423-390-3340
Practice Address - Street 1:3019 PEOPLES ST # CONDO300
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-1977
Practice Address - Country:US
Practice Address - Phone:423-461-2100
Practice Address - Fax:423-461-2199
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-30
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TNMD48521207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program