MEDICARE: MARY K. MCDONALD MD PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2081P2900X	Pain Medicine (Physical Medicine & Rehabilitation) Physician	28536	TN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	P00194880	OTHER		MEDICARE RAILROAD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4097642	OTHER	TN	BLUE CROSS AND BLUE SHIELD

General Provider Information

NPI Number	:	1407944168
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARY K. MCDONALD MD PLLC

Provider Business Mailing Address
First Line	:	PO BOX 22816
Second Line	:
City	:	CHATTANOOGA
State	:	TN
Zip	:	37422-2816
Country	:	US
Telephone Number	:	423-648-7667
Fax Number	:	423-648-6279

Provider Business Practice Location Address
First Line	:	5211 HIGHWAY 153
Second Line	:	SUITE M
City	:	HIXSON
State	:	TN
Zip	:	37343-4956
Country	:	US
Telephone Number	:	423-648-7667
Fax Number	:	423-648-6279

Authorized Official
Title or Position	:	DIRECTOR PHYSICIAN
Name	:	MARY K MCDONALD
Credential	:	M.D.
Telephone Number	:	423-648-7667

Provider Enumeration Date	:	10/10/2006
Last Update Date	:	04/25/2008

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