Healthcare Provider Details

I. General information

NPI: 1033173398
Provider Name (Legal Business Name): JOHN WADE MCKINNEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2006
Last Update Date: 11/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

437 HULSEY RD
BOURBON MO
65441-8159
US

IV. Provider business mailing address

437 HULSEY RD
BOURBON MO
65441-8159
US

V. Phone/Fax

Practice location:
  • Phone: 573-732-3499
  • Fax: 573-732-3499
Mailing address:
  • Phone: 573-732-3499
  • Fax: 573-732-3499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberR6B87
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: