Provider Demographics
NPI:1407881154
Name:MCKINLEY, CHARLES TIMOTHY (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:TIMOTHY
Last Name:MCKINLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT ORAB
Mailing Address - State:OH
Mailing Address - Zip Code:45154-8265
Mailing Address - Country:US
Mailing Address - Phone:937-444-0952
Mailing Address - Fax:937-444-0953
Practice Address - Street 1:621 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MOUNT ORAB
Practice Address - State:OH
Practice Address - Zip Code:45154-8265
Practice Address - Country:US
Practice Address - Phone:937-444-0952
Practice Address - Fax:937-444-0953
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2017-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.051398207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0646368Medicaid
OHH052181Medicare PIN
OH0574921Medicare PIN