1770575615 NPI number — DR. MICHAEL F KENNER DO

Table of content: DR. MICHAEL F KENNER DO (NPI 1770575615)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770575615 NPI number — DR. MICHAEL F KENNER DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KENNER
Provider First Name:
MICHAEL
Provider Middle Name:
F
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1770575615
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/29/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
938 W MAIN ST
Provider Second Line Business Mailing Address:
SUITE 2
Provider Business Mailing Address City Name:
HILLSBORO
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45133-7484
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-393-4390
Provider Business Mailing Address Fax Number:
937-393-4640

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
938 W MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
HILLSBORO
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45133-7484
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-393-4390
Provider Business Practice Location Address Fax Number:
937-393-4640
Provider Enumeration Date:
08/17/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  34004486 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2355062 . This is a "RHC MEDICAID CLINIC #" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 363843 . This is a "RHC MEDICARE CLINIC #" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0688671 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00665503 . This is a "MEDICARE RR" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 311674981 . This is a "OTHER FACILITY TAX ID #" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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