MEDICARE: MCKINNON EYE CLINIC PA

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	207W00000X	Ophthalmology Physician	27825	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1750456836
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MCKINNON EYE CLINIC PA

Provider Business Mailing Address
First Line	:	PO BOX 991
Second Line	:
City	:	STATESVILLE
State	:	NC
Zip	:	28687
Country	:	US
Telephone Number	:	704-873-1463
Fax Number	:	704-873-1467

Provider Business Practice Location Address
First Line	:	1835 DAVIE AVENUE
Second Line	:	SUITE 413
City	:	STATESVILLE
State	:	NC
Zip	:	28677
Country	:	US
Telephone Number	:	704-873-1463
Fax Number	:	704-873-1467

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. STEVE M MCKINNON
Credential	:	MD
Telephone Number	:	704-873-1463

Provider Enumeration Date	:	11/22/2006
Last Update Date	:	07/08/2008

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