Provider Demographics
NPI:1073556528
Name:MCKENNA, MICHAEL G
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:G
Last Name:MCKENNA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 W GERMANTOWN PIKE STE 250
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH MEETING
Mailing Address - State:PA
Mailing Address - Zip Code:19462-1421
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:211 S GULPH RD
Practice Address - Street 2:
Practice Address - City:KING OF PRUSSIA
Practice Address - State:PA
Practice Address - Zip Code:19406-3112
Practice Address - Country:US
Practice Address - Phone:610-382-5900
Practice Address - Fax:610-382-5919
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-13
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA0600332085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7374704Medicaid
NJ904254AHEMedicare PIN
F31936Medicare UPIN
NJ904254ZANLMedicare PIN