Provider Demographics
NPI:1235304320
Name:PAUL S KENYON, MD PC
Entity Type:Organization
Organization Name:PAUL S KENYON, MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:S
Authorized Official - Last Name:KENYON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:517-787-6924
Mailing Address - Street 1:PO BOX 600
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49204-0600
Mailing Address - Country:US
Mailing Address - Phone:517-787-6924
Mailing Address - Fax:517-787-8335
Practice Address - Street 1:150 S EAST AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-2412
Practice Address - Country:US
Practice Address - Phone:517-787-6924
Practice Address - Fax:517-787-8335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-29
Last Update Date:2010-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI49140207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0380337OtherBCBSM
MI2572436Medicaid
MI2572436Medicaid
0481370001Medicare NSC