1902903511 NPI number — DR. STEPHEN M MCKINLEY OD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902903511 NPI number — DR. STEPHEN M MCKINLEY OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCKINLEY
Provider First Name:
STEPHEN
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1902903511
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/03/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 306
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FERGUSON
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42533-0306
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-492-2211
Provider Business Mailing Address Fax Number:
606-676-0873

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
86 MEDICAL LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WHITLEY CITY
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42653-4216
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-376-5258
Provider Business Practice Location Address Fax Number:
606-376-2045
Provider Enumeration Date:
09/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  2659 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: 1676DT , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 01177961 . This is a "AMERIGROUP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3946892 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7100010460 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: DG5893 . This is a "RAILROAD MEDICARE GROUP # FOR WILLIAMSBURG" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 7100209960 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7100212600 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4163597 . This is a "TENNCARE/BLUECARE/BCBSTN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 5185 . This is a "AVESIS/MEDICAID" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: PO0760685 . This is a "RAILROAD MEDICARE FOR JELLICO" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00443168 . This is a "RAILROAD MEDICARE(PTAN)" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 3946891 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7100209950 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7100210000 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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