1578677068 NPI number — DR. JULIE RENEE KENNON M.D.

Table of content: DR. JULIE RENEE KENNON M.D. (NPI 1578677068)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578677068 NPI number — DR. JULIE RENEE KENNON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KENNON
Provider First Name:
JULIE
Provider Middle Name:
RENEE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

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:
1578677068
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/08/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 636493
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CINCINNATI
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45263-6493
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
513-981-5130
Provider Business Mailing Address Fax Number:
513-981-5015

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
749 IRVINE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLAY CITY
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40312-9732
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-663-2153
Provider Business Practice Location Address Fax Number:
606-663-7966
Provider Enumeration Date:
08/19/2006

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: 207Q00000X , with the licence number:  33379 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 64007891 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 607850200 . This is a "FEDERAL BLACK LUNG" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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