Provider Demographics
NPI:1720094089
Name:MCKENZIE, MATTHEW J (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:J
Last Name:MCKENZIE
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:PO BOX 5116
Mailing Address - Street 2:810 EAST 23RD STREET ORTHOPEDIC INSTITUTE
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5116
Mailing Address - Country:US
Mailing Address - Phone:605-331-5890
Mailing Address - Fax:605-336-3974
Practice Address - Street 1:810 EAST 23RD STREET
Practice Address - Street 2:ORTHOPEDIC INSTITUTE
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57117-5116
Practice Address - Country:US
Practice Address - Phone:605-331-5890
Practice Address - Fax:605-336-3974
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2008-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD5001207X00000X
MN35462207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD7301470Medicaid
F34158Medicare UPIN
SD7301470Medicaid