Provider Demographics
NPI:1043401672
Name:KENERSON, KEVIN R (DO)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:R
Last Name:KENERSON
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:174 S FREEPORT RD
Mailing Address - Street 2:SUITE 2A
Mailing Address - City:FREEPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04032-6145
Mailing Address - Country:US
Mailing Address - Phone:855-239-3556
Mailing Address - Fax:207-512-5909
Practice Address - Street 1:174 S FREEPORT RD
Practice Address - Street 2:SUITE 2A
Practice Address - City:FREEPORT
Practice Address - State:ME
Practice Address - Zip Code:04032-6145
Practice Address - Country:US
Practice Address - Phone:855-239-3556
Practice Address - Fax:207-512-5909
Is Sole Proprietor?:No
Enumeration Date:2007-08-08
Last Update Date:2022-07-25
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Provider Licenses
StateLicense IDTaxonomies
ME2105207Q00000X, 2083A0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2083A0300XAllopathic & Osteopathic PhysiciansPreventive MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME001210702Medicare PIN