Provider Demographics
NPI:1881620565
Name:MCKENZIE, PATRICK J (MD)
Entity type:Individual
Prefix:DR
First Name:PATRICK
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 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7226
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:1630 COMMANCHE AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54313-5753
Practice Address - Country:US
Practice Address - Phone:920-593-5555
Practice Address - Fax:920-445-7289
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI25996-20207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31480700Medicaid
WIK400179812Medicare Oscar/Certification
WIC75438Medicare UPIN
WIK400270397Medicare Oscar/Certification
WIK400193351Medicare Oscar/Certification
WIK400209130Medicare Oscar/Certification
WI001107027Medicare PIN