Healthcare Provider Details

I. General information

NPI: 1235132390
Provider Name (Legal Business Name): MARY K MCNEAL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2005
Last Update Date: 02/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 CRESTVIEW PARK DR
DICKSON TN
37055-2850
US

IV. Provider business mailing address

127 CRESTVIEW PARK DR
DICKSON TN
37055-2850
US

V. Phone/Fax

Practice location:
  • Phone: 615-441-4411
  • Fax: 615-446-1357
Mailing address:
  • Phone: 615-441-4478
  • Fax: 615-446-1357

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD35415
License Number StateTN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier370019483
Identifier TypeOTHER
Identifier State
Identifier IssuerRAILROAD MEDICARE PIN
# 2
Identifier3867251
Identifier TypeMEDICAID
Identifier StateTN
Identifier Issuer
# 3
Identifier4041304
Identifier TypeOTHER
Identifier StateTN
Identifier IssuerBLUE CROSS BLUE SHIELD TN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: