Provider Demographics
NPI:1548204878
Name:MCMULLEN, KENNEDY (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNEDY
Middle Name:
Last Name:MCMULLEN
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 1:442 JACKSON BLVD
Mailing Address - Street 2:APT. 1N
Mailing Address - City:FOREST PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60130-1751
Mailing Address - Country:US
Mailing Address - Phone:708-209-1899
Mailing Address - Fax:
Practice Address - Street 1:442 JACKSON BLVD
Practice Address - Street 2:APT. 1N
Practice Address - City:FOREST PARK
Practice Address - State:IL
Practice Address - Zip Code:60130-1751
Practice Address - Country:US
Practice Address - Phone:708-209-1899
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILH75696Medicare UPIN