Provider Demographics
NPI:1902903511
Name:MCKINLEY, STEPHEN M (OD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:M
Last Name:MCKINLEY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 306
Mailing Address - Street 2:
Mailing Address - City:FERGUSON
Mailing Address - State:KY
Mailing Address - Zip Code:42533-0306
Mailing Address - Country:US
Mailing Address - Phone:606-492-2211
Mailing Address - Fax:606-676-0873
Practice Address - Street 1:86 MEDICAL LN
Practice Address - Street 2:
Practice Address - City:WHITLEY CITY
Practice Address - State:KY
Practice Address - Zip Code:42653-4216
Practice Address - Country:US
Practice Address - Phone:606-376-5258
Practice Address - Fax:606-376-2045
Is Sole Proprietor?:No
Enumeration Date:2006-09-19
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2659152W00000X
KY1676DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
01177961OtherAMERIGROUP
TN3946892Medicaid
KY7100010460Medicaid
KYDG5893OtherRAILROAD MEDICARE GROUP # FOR WILLIAMSBURG
KY7100209960Medicaid
KY7100212600Medicaid
TN4163597OtherTENNCARE/BLUECARE/BCBSTN
KY5185OtherAVESIS/MEDICAID
PO0760685OtherRAILROAD MEDICARE FOR JELLICO
KYP00443168OtherRAILROAD MEDICARE(PTAN)
TN3946891Medicaid
KY7100209950Medicaid
KY7100210000Medicaid
TN4163597OtherTENNCARE/BLUECARE/BCBSTN
KY0880905Medicare PIN
PO0760685OtherRAILROAD MEDICARE FOR JELLICO
KYDG5893OtherRAILROAD MEDICARE GROUP # FOR WILLIAMSBURG
01177961OtherAMERIGROUP
TN3946891Medicare PIN
KY0241609Medicare PIN