Provider Demographics
NPI:1720310469
Name:GORDON K MACKENZIE MD PS
Entity Type:Organization
Organization Name:GORDON K MACKENZIE MD PS
Other - Org Name:G KEITH MACKENZIE MD PS
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCKEEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-624-9217
Mailing Address - Street 1:715 S COWLEY ST
Mailing Address - Street 2:SUITE 228
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99202-1383
Mailing Address - Country:US
Mailing Address - Phone:509-624-9217
Mailing Address - Fax:509-623-2187
Practice Address - Street 1:715 S COWLEY ST
Practice Address - Street 2:SUITE 228
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99202-1375
Practice Address - Country:US
Practice Address - Phone:509-624-9217
Practice Address - Fax:509-623-2187
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-05
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD 00015774208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1508100Medicaid
WAA07295Medicare UPIN
WA300938Medicare PIN