Provider Demographics
NPI:1386859775
Name:KENDRA, JEREMY S (MD)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:S
Last Name:KENDRA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3601 W 13 MILE RD
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-6712
Mailing Address - Country:US
Mailing Address - Phone:248-551-0424
Mailing Address - Fax:248-551-5426
Practice Address - Street 1:1000 HARRINGTON ST
Practice Address - Street 2:
Practice Address - City:MOUNT CLEMENS
Practice Address - State:MI
Practice Address - Zip Code:48043-2920
Practice Address - Country:US
Practice Address - Phone:586-493-8098
Practice Address - Fax:586-493-8706
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2010-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010843692085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI310E011330OtherBCBS MI GROUP PIN
MICI8050OtherMEDICARE RR GROUP PIN
MICI8050OtherMEDICARE RR GROUP PIN