Provider Demographics
NPI:1699324103
Name:PHILLIP M. MCKEAN PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:PHILLIP M. MCKEAN PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:VICKEY
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:HULLINGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-486-2339
Mailing Address - Street 1:6605 E STATE BLVD STE 7
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46815-7036
Mailing Address - Country:US
Mailing Address - Phone:260-486-2339
Mailing Address - Fax:260-486-3219
Practice Address - Street 1:6605 E STATE BLVD STE 7
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46815-7036
Practice Address - Country:US
Practice Address - Phone:260-486-2339
Practice Address - Fax:260-486-3219
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-06
Last Update Date:2019-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300028091Medicaid