Provider Demographics
NPI:1063410231
Name:MCKINLEY, RUSSELL LYNN (DPM)
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:LYNN
Last Name:MCKINLEY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 6188
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42702-6188
Mailing Address - Country:US
Mailing Address - Phone:270-769-1303
Mailing Address - Fax:270-769-1310
Practice Address - Street 1:708 WESTPORT RD
Practice Address - Street 2:SUITE 102
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-3819
Practice Address - Country:US
Practice Address - Phone:270-769-1303
Practice Address - Fax:270-769-1310
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-12
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY280213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY50002169OtherPASSPORT
KY000000300214OtherANTHEM
KY80000383Medicaid
KYP00068624OtherRAILROAD MEDICARE
KY618577OtherWELLCARE MEDICAID
KY0775001Medicare PIN
KY50002169OtherPASSPORT