Basic Information
| Provider Information | |||||||||
| NPI: | 1053311910 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MC KENZIE | ||||||||
| FirstName: | EARL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | III | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1300 MEDICAL DR | ||||||||
| Address2: | |||||||||
| City: | TALLAHASSEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323084646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8502160100 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1300 MEDICAL DR | ||||||||
| Address2: | |||||||||
| City: | TALLAHASSEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323084646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8502160100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | ME17224 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | 012109 | GA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 00000 | 01 | FL | BCBSFL | OTHER | 00000 | 01 | FL | HUMANA CHOICE CARE | OTHER | 00000 | 01 | FL | SOUTHCARE | OTHER | 00000 | 01 | FL | UNIVERSAL HEALTH CARE | OTHER | 00000 | 01 | FL | UNITED HEALTH CARE | OTHER | 00239676A | 05 | GA | MEDICAID | 00000 | 01 | FL | BEECH ST/CAPP CARE | OTHER |