Provider Demographics
NPI:1194023374
Name:STEPHEN J. MCKENNA LLC
Entity Type:Organization
Organization Name:STEPHEN J. MCKENNA LLC
Other - Org Name:MCKENNA SURGICAL ASSOCIATES, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:J
Authorized Official - Last Name:MCKENNA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:240-457-4605
Mailing Address - Street 1:7211 BANK CT
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21703-8483
Mailing Address - Country:US
Mailing Address - Phone:240-457-4605
Mailing Address - Fax:240-457-4631
Practice Address - Street 1:7211 BANK CT
Practice Address - Street 2:SUITE 200
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21703-8483
Practice Address - Country:US
Practice Address - Phone:240-457-4605
Practice Address - Fax:240-457-4631
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-11
Last Update Date:2013-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD31422174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD483881500Medicaid
MD201157Medicare PIN
MD483881500Medicaid