Healthcare Provider Details

I. General information

NPI: 1376657270
Provider Name (Legal Business Name): JOHNNY MICHAEL MCCORMICK CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 MCARTHUR STREET UNITED REGIONAL MEDICAL CENTER
MANCHESTER TN
37355
US

IV. Provider business mailing address

308 AMHERST DRIVE
TULLAHOMA TN
37388
US

V. Phone/Fax

Practice location:
  • Phone: 931-728-3586
  • Fax: 931-728-6877
Mailing address:
  • Phone: 931-393-3515
  • Fax: 931-728-6877

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberD34444
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: