Provider Demographics
NPI:1598030264
Name:M POLLY MCKINSTRY MD PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:M POLLY MCKINSTRY MD PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LAVINIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CRUMP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-645-2250
Mailing Address - Street 1:23961 CALLE DE LA MAGDALENA STE 402
Mailing Address - Street 2:
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-3685
Mailing Address - Country:US
Mailing Address - Phone:949-595-0095
Mailing Address - Fax:949-595-4459
Practice Address - Street 1:23961 CALLE DE LA MAGDALENA STE 402
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-3685
Practice Address - Country:US
Practice Address - Phone:949-595-0095
Practice Address - Fax:949-595-4459
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:M POLLY MCKINSTRY MD PROFESSIONAL CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-03-14
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG54934B208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG54934BMedicare UPIN