Basic Information
Provider Information | |||||||||
NPI: | 1013957976 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MCDONALD | ||||||||
FirstName: | GARY | ||||||||
MiddleName: | R. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 104 WOODMONT BLVD | ||||||||
Address2: | SUITE LL50 | ||||||||
City: | NASHVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 372052245 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6153862300 | ||||||||
FaxNumber: | 6153862399 | ||||||||
Practice Location | |||||||||
Address1: | 4230 HARDING RD | ||||||||
Address2: | SUITE 400 | ||||||||
City: | NASHVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 372052013 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6152972700 | ||||||||
FaxNumber: | 6152694584 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/08/2006 | ||||||||
LastUpdateDate: | 08/07/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 20283 | TN | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 12219843 | 01 | TN | MULTIPLAN/PHCS | OTHER | 64916265 | 05 | KY |   | MEDICAID | 977796 | 01 | TN | UNITED HEALTH CARE | OTHER | 1074558 | 01 | TN | USA MCO | OTHER | 3164324 | 01 | TN | BLUE CROSS OF TN | OTHER | 10078366 | 01 | TN | AMERIGROUP | OTHER | 1507823 | 05 | TN |   | MEDICAID | 110220160 | 01 | TN | MEDICARE RR | OTHER | 2571436 | 01 | TN | CIGNA | OTHER |