Basic Information
| Provider Information | |||||||||
| NPI: | 1063425213 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCKENZIE | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 301 EXPLORER ST | ||||||||
| Address2: | |||||||||
| City: | GWINN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 498412813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9063464924 | ||||||||
| FaxNumber: | 9063466474 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 CAMPUS DR | ||||||||
| Address2: | |||||||||
| City: | HANCOCK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 499301569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9064831060 | ||||||||
| FaxNumber: | 9064831066 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2006 | ||||||||
| LastUpdateDate: | 04/14/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4301053781 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 103097998 | 05 | MI | MEDICAID | 0829560001 | 01 | MI | MEDICARE DME | OTHER | 0C16002 | 01 | MI | MEDICARE GROUP | OTHER | DM053781 | 01 | MI | BLUECROSS STATE ID | OTHER |