Basic Information
| Provider Information | |||||||||
| NPI: | 1376657270 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCCORMICK | ||||||||
| FirstName: | JOHNNY | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 308 AMHERST DRIVE | ||||||||
| Address2: | |||||||||
| City: | TULLAHOMA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37388 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9313933515 | ||||||||
| FaxNumber: | 9317286877 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 MCARTHUR STREET | ||||||||
| Address2: | UNITED REGIONAL MEDICAL CENTER | ||||||||
| City: | MANCHESTER | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37355 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9317283586 | ||||||||
| FaxNumber: | 9317286877 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | D34444 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 3250236 | 05 | TN | MEDICAID | 4085915 | 01 | TN | BLUE CROSS BLUE SHIELD | OTHER |