Provider Demographics
NPI:1225330087
Name:EDWARD F MCKENNEY D O S C
Entity Type:Organization
Organization Name:EDWARD F MCKENNEY D O S C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:F
Authorized Official - Last Name:MCKENNEY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:217-847-3383
Mailing Address - Street 1:1471 KEOKUK ST
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:IL
Mailing Address - Zip Code:62341-1135
Mailing Address - Country:US
Mailing Address - Phone:217-847-3383
Mailing Address - Fax:217-847-2832
Practice Address - Street 1:1471 KEOKUK ST
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:IL
Practice Address - Zip Code:62341-1135
Practice Address - Country:US
Practice Address - Phone:217-847-3383
Practice Address - Fax:217-847-2832
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-30
Last Update Date:2011-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036058009207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036058009Medicaid
ILIL4126OtherGROUP PTAN
ILIL4126001OtherINDIVIDUAL PTAN
ILD09860Medicare UPIN