Provider Demographics
NPI:1427032515
Name:KENNY, JAMES NICHOLAS JR (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:NICHOLAS
Last Name:KENNY
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:900 MAIN ST
Mailing Address - Street 2:STE 530B
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61602-5007
Mailing Address - Country:US
Mailing Address - Phone:309-655-7700
Mailing Address - Fax:309-624-8790
Practice Address - Street 1:200 E PENNSYLVANIA AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603-3089
Practice Address - Country:US
Practice Address - Phone:309-655-7700
Practice Address - Fax:309-624-8790
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036072378208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036072378Medicaid
ILL36463Medicare ID - Type UnspecifiedPIN PEKIN
ILE18419Medicare UPIN
ILL20543Medicare PIN
IL979010Medicare PIN