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NPI Code Detail

MEDICARE: MARY RUSSELL MCCORMICK M.D.

MEDICARE: MARY RUSSELL MCCORMICK M.D.
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
1390200000XStudent in an Organized Health Care Education/Training Program
2207Q00000XFamily Medicine PhysicianMD48521TN

General Provider Information

NPI Number : 1568693133
Entity Type Code : Individual
Provider Name (Legal Business Name) : MARY RUSSELL MCCORMICK M.D.
Provider Business Mailing Address
First Line : PO BOX 9
Second Line :
City : KINGSPORT
State : TN
Zip : 37662-0009
Country : US
Telephone Number : 423-857-2093
Fax Number : 423-390-3340
Provider Business Practice Location Address
First Line : 3019 PEOPLES ST # CONDO300
Second Line :
City : JOHNSON CITY
State : TN
Zip : 37604-1977
Country : US
Telephone Number : 423-461-2100
Fax Number : 423-461-2199
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/30/2009
Last Update Date : 03/30/2021

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