Provider Demographics
NPI:1407304017
Name:MCKINLEY SPORTS MEDICINE, LLC
Entity Type:Organization
Organization Name:MCKINLEY SPORTS MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:K
Authorized Official - Last Name:MALCOLM
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:907-456-3341
Mailing Address - Street 1:3745 GEIST RD
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709-3554
Mailing Address - Country:US
Mailing Address - Phone:907-456-3341
Mailing Address - Fax:907-456-3443
Practice Address - Street 1:3745 GEIST RD
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-3554
Practice Address - Country:US
Practice Address - Phone:907-456-3341
Practice Address - Fax:907-456-3443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-13
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK10040231207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Single Specialty