Provider Demographics
NPI:1427013952
Name:KENNY, AGNES (MD)
Entity Type:Individual
Prefix:DR
First Name:AGNES
Middle Name:
Last Name:KENNY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1694 W LOGANSPORT RD
Mailing Address - Street 2:
Mailing Address - City:PERU
Mailing Address - State:IN
Mailing Address - Zip Code:46970-3149
Mailing Address - Country:US
Mailing Address - Phone:765-472-2812
Mailing Address - Fax:765-472-2970
Practice Address - Street 1:1694 W LOGANSPORT RD
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IN
Practice Address - Zip Code:46970-3149
Practice Address - Country:US
Practice Address - Phone:765-472-2812
Practice Address - Fax:765-472-2970
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2016-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01031072A208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1002555200Medicaid
IN000000752605OtherANTHEM
INP01011306OtherRAILROAD
IN221480EMedicare PIN
IND69743Medicare UPIN
INM400063941Medicare Oscar/Certification