Provider Demographics
NPI:1558352294
Name:MCKENNA, TIMOTHY MELVIN (DO)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:MELVIN
Last Name:MCKENNA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1675 WATERTOWER PLACE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823
Mailing Address - Country:US
Mailing Address - Phone:517-332-0200
Mailing Address - Fax:517-332-0963
Practice Address - Street 1:1675 WATERTOWER PLACE
Practice Address - Street 2:SUITE 100
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823
Practice Address - Country:US
Practice Address - Phone:517-332-0200
Practice Address - Fax:517-332-0963
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2011-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101007174208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1544295Medicaid
D69690Medicare UPIN
MIC36057Medicare ID - Type Unspecified