Provider Demographics
NPI:1548463185
Name:MCKENNEY MEDICAL GROUP, PLLC
Entity type:Organization
Organization Name:MCKENNEY MEDICAL GROUP, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JULIAN
Authorized Official - Middle Name:DEW
Authorized Official - Last Name:MCKENNEY
Authorized Official - Suffix:JR
Authorized Official - Credentials:DO
Authorized Official - Phone:757-657-9595
Mailing Address - Street 1:6712A S QUAY RD
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23437-8697
Mailing Address - Country:US
Mailing Address - Phone:757-657-9595
Mailing Address - Fax:757-657-9950
Practice Address - Street 1:6712A S QUAY RD
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23437-8697
Practice Address - Country:US
Practice Address - Phone:757-657-9595
Practice Address - Fax:757-657-9950
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-11
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102037167207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0102037167OtherSTATE LICENSE
VABM 3396377OtherDEA
VA0102037167OtherSTATE LICENSE