Provider Demographics
NPI:1447200688
Name:MCKINNIE, MICHAEL V JR (PT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:V
Last Name:MCKINNIE
Suffix:JR
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:623 LANTERN PARK LN
Mailing Address - Street 2:
Mailing Address - City:SCOTTDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30079-6813
Mailing Address - Country:US
Mailing Address - Phone:404-294-9875
Mailing Address - Fax:
Practice Address - Street 1:550 FAIRBURN RD SW
Practice Address - Street 2:SUITE B-1
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30331-2014
Practice Address - Country:US
Practice Address - Phone:404-696-4449
Practice Address - Fax:404-696-3422
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT007467225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP99012Medicare UPIN
GA65BBCLZMedicare ID - Type Unspecified