MEDICARE: MCKENNEY MEDICAL GROUP, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	0102037167	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0102037167	OTHER	VA	STATE LICENSE

General Provider Information

NPI Number	:	1548463185
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MCKENNEY MEDICAL GROUP, PLLC

Provider Business Mailing Address
First Line	:	6712A S QUAY RD
Second Line	:
City	:	SUFFOLK
State	:	VA
Zip	:	23437-8697
Country	:	US
Telephone Number	:	757-657-9595
Fax Number	:	757-657-9950

Provider Business Practice Location Address
First Line	:	6712A S QUAY RD
Second Line	:
City	:	SUFFOLK
State	:	VA
Zip	:	23437-8697
Country	:	US
Telephone Number	:	757-657-9595
Fax Number	:	757-657-9950

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JULIAN DEW MCKENNEY JR.
Credential	:	D.O.
Telephone Number	:	757-657-9595

Provider Enumeration Date	:	06/11/2007
Last Update Date	:	03/07/2023

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