Provider Demographics
NPI:1821064122
Name:MCKENZIE, MARK M (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:M
Last Name:MCKENZIE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6031 SHALLOWFORD RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-1983
Mailing Address - Country:US
Mailing Address - Phone:423-468-3923
Mailing Address - Fax:423-468-3927
Practice Address - Street 1:6031 SHALLOWFORD RD
Practice Address - Street 2:SUITE 105
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-1983
Practice Address - Country:US
Practice Address - Phone:423-468-3923
Practice Address - Fax:423-468-3927
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-27
Last Update Date:2011-12-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN35982207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4158363OtherBCBS
SC4178417OtherBCBS
TN38720281Medicaid
TN38720281Medicare PIN
TN4158363OtherBCBS
SC4178417OtherBCBS
TN38720281Medicaid
TNH56860Medicare UPIN