Provider Demographics
NPI:1184633711
Name:MCKENNA, RUSSEL T (DO)
Entity Type:Individual
Prefix:
First Name:RUSSEL
Middle Name:T
Last Name:MCKENNA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1325 N 600 E STE 101
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341
Mailing Address - Country:US
Mailing Address - Phone:435-750-5599
Mailing Address - Fax:435-750-0861
Practice Address - Street 1:1325 N 600 E STE 101
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341
Practice Address - Country:US
Practice Address - Phone:435-750-5599
Practice Address - Fax:435-750-0861
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2851791204208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
I06230Medicare UPIN
UT005750702Medicare ID - Type Unspecified