Provider Demographics
NPI:1821476193
Name:MCKINNEY MEDICAL CENTER INC
Entity Type:Organization
Organization Name:MCKINNEY MEDICAL CENTER INC
Other - Org Name:MCKINNEY MEDICAL CENTER, INC
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:CEO
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:31501-3547
Mailing Address - Country:US
Mailing Address - Phone:912-287-0301
Mailing Address - Fax:912-287-1568
Practice Address - Street 1:711 CHARLES GILMAN JR AVE STE B
Practice Address - Street 2:
Practice Address - City:KINGSLAND
Practice Address - State:GA
Practice Address - Zip Code:31548-5664
Practice Address - Country:US
Practice Address - Phone:912-510-9728
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MCKINNEY MEDICAL CENTER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-05-07
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAK408492261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)