Provider Demographics
NPI:1912086414
Name:MACKEY, GEORGE (PT)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:
Last Name:MACKEY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7541 9TH ST N
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55128-6626
Mailing Address - Country:US
Mailing Address - Phone:651-748-4338
Mailing Address - Fax:
Practice Address - Street 1:20 THOMPSON AVE E
Practice Address - Street 2:SUITE 103
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55118-3187
Practice Address - Country:US
Practice Address - Phone:651-455-2447
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2009-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1670225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN087018800Medicaid
MN087018800Medicaid