Healthcare Provider Details

I. General information

NPI: 1790213783
Provider Name (Legal Business Name): MATTHEW JAMES MACKAY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2017
Last Update Date: 11/28/2023
Certification Date: 11/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10701 NALL AVE STE 200
OVERLAND PARK KS
66211-1358
US

IV. Provider business mailing address

10701 NALL AVE STE 200
OVERLAND PARK KS
66211-1358
US

V. Phone/Fax

Practice location:
  • Phone: 806-680-2652
  • Fax:
Mailing address:
  • Phone: 806-680-2652
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number2022008451
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number04-45829
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: