Provider Demographics
NPI:1518123124
Name:KINNEY, DANIEL MATTHEW (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:MATTHEW
Last Name:KINNEY
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 1:710 N NILES AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1924
Mailing Address - Country:US
Mailing Address - Phone:574-647-1610
Mailing Address - Fax:
Practice Address - Street 1:1815 E IRELAND RD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46614-2845
Practice Address - Country:US
Practice Address - Phone:574-647-1700
Practice Address - Fax:574-647-1708
Is Sole Proprietor?:No
Enumeration Date:2008-08-03
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01068216A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200985830Medicaid
IN000000943897OtherBCBS BMG IRELAND RD
IN000000662131OtherBCBS BMG MAIN STREET
IN000000660633OtherBCBS BMG MEMORIAL CHILDRENS
INM400019016Medicare PIN
IN000000943897OtherBCBS BMG IRELAND RD
IN200985830Medicaid