Provider Demographics
NPI:1417051715
Name:MCKENNA, JOHN M (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:M
Last Name:MCKENNA
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 1:630 PLANTATION ST
Mailing Address - Street 2:WOT 12TH FL ATTN PHYSICIAN SERVICES
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605
Mailing Address - Country:US
Mailing Address - Phone:508-368-5529
Mailing Address - Fax:508-368-5530
Practice Address - Street 1:425 NORTH LAKE AVE
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605
Practice Address - Country:US
Practice Address - Phone:508-595-2513
Practice Address - Fax:508-854-0822
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA37188207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
W10105401OtherCIGNA HEALTH PLAN
0400980OtherEVERCARE
917962OtherFIRST HEALTH
E09004OtherBLUE CROSS
MA3100448Medicaid
3548152OtherCIGNA HEALTH PLAN
9410342002OtherCIGNA HEALTH PLAN
3100448OtherMEDICAID WELFARE
3100448OtherMEDICAID WELFARE
MAE09004Medicare ID - Type Unspecified
E09004Medicare ID - Type UnspecifiedB