Provider Demographics
NPI:1801907324
Name:MCKAIN, MARK KELLY (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:KELLY
Last Name:MCKAIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:253 MARTIN STREET
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-4532
Mailing Address - Country:US
Mailing Address - Phone:208-733-0482
Mailing Address - Fax:208-734-0263
Practice Address - Street 1:253 MARTIN STREET
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-4532
Practice Address - Country:US
Practice Address - Phone:208-733-0482
Practice Address - Fax:208-734-0263
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM6053208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
F36972Medicare UPIN
ID1126529Medicare ID - Type Unspecified