Basic Information
| Provider Information | |||||||||
| NPI: | 1245419795 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MCKINLEY OB/GYN ASSOCIATES PC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MCKINLEY OB/GYN ASSOCIATES PC LAB | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1086 FRANKLIN ST | ||||||||
| Address2: | |||||||||
| City: | JOHNSTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 159054305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8144108300 | ||||||||
| FaxNumber: | 8144108331 | ||||||||
| Practice Location | |||||||||
| Address1: | 1481 EISENHOWER BLVD | ||||||||
| Address2: | |||||||||
| City: | JOHNSTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 159043217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8142627470 | ||||||||
| FaxNumber: | 8142627472 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2007 | ||||||||
| LastUpdateDate: | 11/01/2007 | ||||||||
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| AuthorizedOfficialLastName: | MCKINLEY | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8142627470 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | MD019054E | PA | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 1015065000002 | 05 | PA | MEDICAID |