Provider Demographics
NPI:1609864511
Name:TYNAN, MACDARA GERARD (MD)
Entity type:Individual
Prefix:
First Name:MACDARA
Middle Name:GERARD
Last Name:TYNAN
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 BLYTHE BLVD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-5812
Mailing Address - Country:US
Mailing Address - Phone:704-318-6800
Mailing Address - Fax:
Practice Address - Street 1:282 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-3322
Practice Address - Country:US
Practice Address - Phone:860-837-5506
Practice Address - Fax:860-837-5540
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-13
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200600478208M00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5903367Medicaid
NC142KKOtherBCBS
SCN78008Medicaid
SCN78008Medicaid
NC2058072AMedicare PIN