Provider Demographics
NPI:1629133459
Name:MCKINNON, MCKAY (MD)
Entity Type:Individual
Prefix:
First Name:MCKAY
Middle Name:
Last Name:MCKINNON
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 1:680 N LAKE SHORE DR STE 1208
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-8701
Mailing Address - Country:US
Mailing Address - Phone:312-335-9566
Mailing Address - Fax:312-335-1681
Practice Address - Street 1:680 N LAKE SHORE DR STE 1208
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611
Practice Address - Country:US
Practice Address - Phone:312-335-9566
Practice Address - Fax:312-335-1681
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1509382086S0122X
IL0360712462086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036071246Medicaid