Healthcare Provider Details

I. General information

NPI: 1407304017
Provider Name (Legal Business Name): MCKINLEY SPORTS MEDICINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2016
Last Update Date: 09/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3745 GEIST RD
FAIRBANKS AK
99709-3554
US

IV. Provider business mailing address

3745 GEIST RD
FAIRBANKS AK
99709-3554
US

V. Phone/Fax

Practice location:
  • Phone: 907-456-3341
  • Fax: 907-456-3443
Mailing address:
  • Phone: 907-456-3341
  • Fax: 907-456-3443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number10040231
License Number StateAK

VIII. Authorized Official

Name: JENNIFER K MALCOLM
Title or Position: PRESIDENT
Credential: DO
Phone: 907-456-3341