Provider Demographics
NPI:1336326610
Name:TIMOTHY W MCKENZIE MD PC
Entity Type:Organization
Organization Name:TIMOTHY W MCKENZIE MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATION
Authorized Official - Prefix:MRS
Authorized Official - First Name:VALERIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:LANDRUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-854-1235
Mailing Address - Street 1:5182 WRIGHTSBORO RD
Mailing Address - Street 2:
Mailing Address - City:GROVETOWN
Mailing Address - State:GA
Mailing Address - Zip Code:30813-2802
Mailing Address - Country:US
Mailing Address - Phone:706-854-1235
Mailing Address - Fax:
Practice Address - Street 1:5182 WRIGHTSBORO RD
Practice Address - Street 2:
Practice Address - City:GROVETOWN
Practice Address - State:GA
Practice Address - Zip Code:30813-2802
Practice Address - Country:US
Practice Address - Phone:706-854-1235
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-29
Last Update Date:2008-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA028834207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAD46087Medicare UPIN
GA08BBXQSMedicare PIN