Healthcare Provider Details

I. General information

NPI: 1629650197
Provider Name (Legal Business Name): MADELYN MCKENZIE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MADELYN GREEN

II. Dates (important events)

Enumeration Date: 04/24/2021
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4117 BROWNS LN
LOUISVILLE KY
40220-1535
US

IV. Provider business mailing address

4117 BROWNS LN
LOUISVILLE KY
40220-1535
US

V. Phone/Fax

Practice location:
  • Phone: 502-452-6337
  • Fax:
Mailing address:
  • Phone: 502-452-6337
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number57.255285
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberTP993
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: