Provider Demographics
NPI:1013158419
Name:SUSAN MCKINLEY, MD
Entity Type:Organization
Organization Name:SUSAN MCKINLEY, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:GOLDSMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-594-2002
Mailing Address - Street 1:731 COMMERCIAL ST
Mailing Address - Street 2:STE 2
Mailing Address - City:ROCKPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04856-4254
Mailing Address - Country:US
Mailing Address - Phone:207-594-2002
Mailing Address - Fax:207-594-5787
Practice Address - Street 1:731 COMMERCIAL ST
Practice Address - Street 2:STE 2
Practice Address - City:ROCKPORT
Practice Address - State:ME
Practice Address - Zip Code:04856-4254
Practice Address - Country:US
Practice Address - Phone:207-594-2002
Practice Address - Fax:207-594-5787
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-13
Last Update Date:2009-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME013052208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME122640000Medicaid