Provider Demographics
NPI:1770787418
Name:BRUCE A MACKEY MD PC
Entity type:Organization
Organization Name:BRUCE A MACKEY MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:A
Authorized Official - Last Name:MACKEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-285-7246
Mailing Address - Street 1:3957 E COVELL RD
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-6909
Mailing Address - Country:US
Mailing Address - Phone:405-285-7246
Mailing Address - Fax:405-285-7546
Practice Address - Street 1:3957 E COVELL RD
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-6909
Practice Address - Country:US
Practice Address - Phone:405-285-7246
Practice Address - Fax:405-285-7546
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-14
Last Update Date:2013-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK16205208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKD34970Medicare UPIN
900522594Medicare PIN