Provider Demographics
NPI:1962460998
Name:MCCONNELL, MICHAEL C (CRNA)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:C
Last Name:MCCONNELL
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1407 UNION AVE
Mailing Address - Street 2:SUITE 640
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-3627
Mailing Address - Country:US
Mailing Address - Phone:901-866-8360
Mailing Address - Fax:901-302-2360
Practice Address - Street 1:1407 UNION AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-3600
Practice Address - Country:US
Practice Address - Phone:901-866-8813
Practice Address - Fax:901-302-2120
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-01
Last Update Date:2011-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN9302367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4010460OtherBLUE CROSS W/MAA
AR136280701OtherMEDICAID W/MAA
TN3607664Medicaid
AR98469OtherBLUE CROSS W/MAA
MS0116747OtherMEDICAID W/MAA
TN430056979OtherRAILROAD MEDICARE W/MAA
MO915066112OtherMEDICAID W/MAA
TN3607663OtherMEDICARE W/MAA
TN3607660OtherMEDICAID W/MAA
TN3607664Medicaid