Provider Demographics
NPI:1487665733
Name:MCKINNEY MEDICAL CENTER INC
Entity Type:Organization
Organization Name:MCKINNEY MEDICAL CENTER INC
Other - Org Name:MCKINNEY COMMUNITY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:OLA
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-287-0301
Mailing Address - Street 1:218 QUARTERMAN ST
Mailing Address - Street 2:
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31501
Mailing Address - Country:US
Mailing Address - Phone:912-287-0301
Mailing Address - Fax:912-287-1568
Practice Address - Street 1:218 QUARTERMAN ST
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501
Practice Address - Country:US
Practice Address - Phone:912-287-9140
Practice Address - Fax:912-287-1568
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MCKINNEY MEDICAL CENTER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-11
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QF0400X
GA261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA336243OtherWELLCARE
GA10066125OtherAMERIGROUP
GA000715415A WAYCROSSMedicaid
GA336243OtherWELLCARE
GA10066125OtherAMERIGROUP
GACF9151Medicare PIN
GACF9151Medicare UPIN