Basic Information
Provider Information | |||||||||
NPI: | 1639410608 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MCCORMICK | ||||||||
FirstName: | CURTIS | ||||||||
MiddleName: | TIMOTHY | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2341 MCCALLIE AVE | ||||||||
Address2: | SUITE 402 | ||||||||
City: | CHATTANOOGA | ||||||||
State: | TN | ||||||||
PostalCode: | 374043239 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4236983309 | ||||||||
FaxNumber: | 4236246355 | ||||||||
Practice Location | |||||||||
Address1: | 2341 MCCALLIE AVE | ||||||||
Address2: | SUITE 402 | ||||||||
City: | CHATTANOOGA | ||||||||
State: | TN | ||||||||
PostalCode: | 374043239 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4236983309 | ||||||||
FaxNumber: | 4236246355 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/15/2013 | ||||||||
LastUpdateDate: | 09/23/2013 | ||||||||
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 | 367500000X | 92445 | FL | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   | 163W00000X | 9312515 | FL | N |   | Nursing Service Providers | Registered Nurse |   | 163W00000X | 133506 | TN | N |   | Nursing Service Providers | Registered Nurse |   | 367500000X | APN17616 | TN | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
ID Information
ID | Type | State | Issuer | Description | 4348852 | 01 | TN | BC BS OF TN | OTHER | 1532135 | 05 | TN |   | MEDICAID |