MEDICARE: DR. JOHN W MCKEAN M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0804X	Child & Adolescent Psychiatry Physician	A18205	CA

General Provider Information

NPI Number	:	1215951017
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN W MCKEAN M.D.

Provider Business Mailing Address
First Line	:	4411 LEVERT AVE
Second Line	:
City	:	DIAMOND SPRINGS
State	:	CA
Zip	:	95619-9738
Country	:	US
Telephone Number	:	530-626-5018
Fax Number	:	530-626-1791

Provider Business Practice Location Address
First Line	:	4411 LEVERT AVE
Second Line	:
City	:	DIAMOND SPRINGS
State	:	CA
Zip	:	95619-9738
Country	:	US
Telephone Number	:	530-626-5018
Fax Number	:	530-626-1791

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/26/2006
Last Update Date	:	07/08/2007

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