Provider Demographics
NPI:1417912460
Name:KENNER, MICHAEL D (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:D
Last Name:KENNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:4900 S MONACO ST
Mailing Address - Street 2:#210
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80237-3486
Mailing Address - Country:US
Mailing Address - Phone:303-750-0822
Mailing Address - Fax:303-750-1298
Practice Address - Street 1:1444 S POTOMAC ST
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80012-4508
Practice Address - Country:US
Practice Address - Phone:303-750-0822
Practice Address - Fax:303-750-1298
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM7936207RC0000X
CO52174207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805657700Medicaid
CO54426065Medicaid
COP01223076Medicare PIN
CO54426065Medicaid
ID805657700Medicaid
CO297018YPNQMedicare PIN