Basic Information
| Provider Information | |||||||||
| NPI: | 1558474460 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCKINLEY | ||||||||
| FirstName: | O | ||||||||
| MiddleName: | BARRY | ||||||||
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| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MCKINLEY | ||||||||
| OtherFirstName: | BARRY | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2999 REGENT ST | ||||||||
| Address2: | 225 | ||||||||
| City: | BERKELEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 947052190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5107047760 | ||||||||
| FaxNumber: | 5107047765 | ||||||||
| Practice Location | |||||||||
| Address1: | 2999 REGENT ST | ||||||||
| Address2: | 225 | ||||||||
| City: | BERKELEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 947052190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5107047760 | ||||||||
| FaxNumber: | 5107047765 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2006 | ||||||||
| LastUpdateDate: | 05/21/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | G11794 | CA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | G11794 | 01 | CA | BLUE CROSS | OTHER | 00G117940 | 01 | CA | BLUE SHIELD | OTHER | G11794 | 01 | CA | STATE LICENSE | OTHER | 00G117940 | 05 | CA | MEDICAID |