Provider Demographics
NPI:1235145061
Name:BAIN, MCKINLEY THEODORE
Entity Type:Individual
Prefix:DR
First Name:MCKINLEY
Middle Name:THEODORE
Last Name:BAIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1930 POWDER SPRINGS RD SW
Mailing Address - Street 2:SUITE 1120
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064-4324
Mailing Address - Country:US
Mailing Address - Phone:770-427-7800
Mailing Address - Fax:470-427-6565
Practice Address - Street 1:1930 POWDER SPRINGS RD SW
Practice Address - Street 2:SUITE 1120
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30064-4324
Practice Address - Country:US
Practice Address - Phone:770-427-7800
Practice Address - Fax:470-427-6565
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2009-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA046826207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00860021DMedicaid
H21635Medicare UPIN
11CCXBMedicare ID - Type Unspecified