Provider Demographics
NPI:1184824617
Name:MICHAEL D KENNER, MD,PC
Entity Type:Organization
Organization Name:MICHAEL D KENNER, MD,PC
Other - Org Name:NONE
Other - Org Type:Other Name
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:KENNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-453-1062
Mailing Address - Street 1:1721 S 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-4839
Mailing Address - Country:US
Mailing Address - Phone:208-453-1062
Mailing Address - Fax:208-453-1196
Practice Address - Street 1:1721 S 10TH AVE
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4839
Practice Address - Country:US
Practice Address - Phone:208-453-1062
Practice Address - Fax:208-453-1196
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-23
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDE93142Medicare UPIN
ID1375355Medicare PIN