Provider Demographics
NPI:1902843089
Name:MCKINLAY, KIRT M (MD)
Entity Type:Individual
Prefix:
First Name:KIRT
Middle Name:M
Last Name:MCKINLAY
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 1:1441 PARKWAY DR
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-1667
Mailing Address - Country:US
Mailing Address - Phone:208-785-2600
Mailing Address - Fax:
Practice Address - Street 1:1441 PARKWAY DR
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-1667
Practice Address - Country:US
Practice Address - Phone:208-785-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-4895207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002331100Medicaid
ID11179511Medicare PIN