Healthcare Provider Details

I. General information

NPI: 1124339858
Provider Name (Legal Business Name): JUSTIN LEIGH MCKINNEY DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2010
Last Update Date: 08/31/2023
Certification Date: 08/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 BROOKS ST STE 200
CHARLESTON WV
25301
US

IV. Provider business mailing address

210 BROOKS ST STE 200
CHARLESTON WV
25301-1848
US

V. Phone/Fax

Practice location:
  • Phone: 304-388-1930
  • Fax: 304-388-1929
Mailing address:
  • Phone: 304-388-1930
  • Fax: 304-388-1929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number25454
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number3424
License Number StateWV
# 3
Primary TaxonomyN
Taxonomy Code2082S0105X
TaxonomySurgery of the Hand (Plastic Surgery) Physician
License Number3424
License Number StateWV
# 4
Primary TaxonomyN
Taxonomy Code2086S0105X
TaxonomySurgery of the Hand (Surgery) Physician
License Number25454
License Number StateMS
# 5
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number25454
License Number StateMS
# 6
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number3424
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: