MEDICARE: DR. JAYME T. MACKAY 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	207Q00000X	Family Medicine Physician	35944	WA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
4	1139255	OTHER	ID	IDAHO MEDICARE NUMBER

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000010001517	OTHER	ID	REGENCE BLUE SHIELD PROV
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	120618	OTHER	WA	DL &I PROV NUMBER
5	52092	OTHER	ID	BLUE CROSS IDAHO

General Provider Information

NPI Number	:	1902804594
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JAYME T. MACKAY M.D.

Provider Business Mailing Address
First Line	:	1271 HIGHLAND AVE
Second Line	:	SUITE A
City	:	CLARKSTON
State	:	WA
Zip	:	99403-2846
Country	:	US
Telephone Number	:	509-751-1500
Fax Number	:	509-751-1504

Provider Business Practice Location Address
First Line	:	1271 HIGHLAND AVE
Second Line	:	SUITE A
City	:	CLARKSTON
State	:	WA
Zip	:	99403-2846
Country	:	US
Telephone Number	:	509-751-1500
Fax Number	:	509-751-1504

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

Provider Enumeration Date	:	07/08/2005
Last Update Date	:	07/08/2007

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