=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568402675
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARYANNE BEATRICE MCDONALD MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/07/2006
-----------------------------------------------------
Last Update Date | 04/24/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | MADIGAN ARMY MEDICAL CENTER 9040 JACKSON AVE
-----------------------------------------------------
City | TACOMA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98431-1100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-968-4185
-----------------------------------------------------
Fax | 253-968-1188
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9040 REID ST
-----------------------------------------------------
City | JOINT BASE LEWIS MCCHORD
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98431-1100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-968-4185
-----------------------------------------------------
Fax | 253-968-1188
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RN0300X
-----------------------------------------------------
Taxonomy Name | Nephrology Physician
-----------------------------------------------------
License Number | MD00020851
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------