Basic Information
| Provider Information | |||||||||
| NPI: | 1962460998 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCONNELL | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1407 UNION AVE | ||||||||
| Address2: | SUITE 640 | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381043627 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9018668360 | ||||||||
| FaxNumber: | 9013022360 | ||||||||
| Practice Location | |||||||||
| Address1: | 1407 UNION AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381043600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9018668813 | ||||||||
| FaxNumber: | 9013022120 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2006 | ||||||||
| LastUpdateDate: | 06/09/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 9302 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 4010460 | 01 | TN | BLUE CROSS W/MAA | OTHER | 136280701 | 01 | AR | MEDICAID W/MAA | OTHER | 3607664 | 05 | TN | MEDICAID | 98469 | 01 | AR | BLUE CROSS W/MAA | OTHER | 0116747 | 01 | MS | MEDICAID W/MAA | OTHER | 430056979 | 01 | TN | RAILROAD MEDICARE W/MAA | OTHER | 915066112 | 01 | MO | MEDICAID W/MAA | OTHER | 3607663 | 01 | TN | MEDICARE W/MAA | OTHER | 3607660 | 01 | TN | MEDICAID W/MAA | OTHER |