Basic Information
| Provider Information | |||||||||
| NPI: | 1629239256 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCKIM | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | ERNEST | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9735 KINCEY AVE | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | HUNTERSVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280789118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7044142870 | ||||||||
| FaxNumber: | 7044142860 | ||||||||
| Practice Location | |||||||||
| Address1: | 12610 N COMMUNITY HOUSE RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282773892 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7047523730 | ||||||||
| FaxNumber: | 7047529056 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2008 | ||||||||
| LastUpdateDate: | 05/27/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 36486 | SC | N | Allopathic & Osteopathic Physicians | Urology | 208800000X | 2013-00734 | NC | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | NC2277 | 05 | SC | MEDICAID |