Provider Demographics
NPI:1760576847
Name:MICHAEL J MCKENNA MD PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:MICHAEL J MCKENNA MD PROFESSIONAL CORPORATION
Other - Org Name:MCKENNA AND RUGGEROLI PAIN SPECIALISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:MCKENNA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-334-0260
Mailing Address - Street 1:8465 W SAHARA AVE STE 111-419
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117-8960
Mailing Address - Country:US
Mailing Address - Phone:702-334-0260
Mailing Address - Fax:
Practice Address - Street 1:8465 W SAHARA AVE STE 111-419
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117-8960
Practice Address - Country:US
Practice Address - Phone:702-334-0260
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV5744174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002002706Medicaid
NV34962Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
NVD42985Medicare UPIN