Provider Demographics
NPI:1548587496
Name:KENNERLY SURGICAL PLLC
Entity Type:Organization
Organization Name:KENNERLY SURGICAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:R
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:KENNERLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-521-2230
Mailing Address - Street 1:809 WILLOW LN
Mailing Address - Street 2:
Mailing Address - City:PT PLEASANT
Mailing Address - State:WV
Mailing Address - Zip Code:25550-2018
Mailing Address - Country:US
Mailing Address - Phone:304-521-2230
Mailing Address - Fax:
Practice Address - Street 1:809 WILLOW LN
Practice Address - Street 2:
Practice Address - City:PT PLEASANT
Practice Address - State:WV
Practice Address - Zip Code:25550-2018
Practice Address - Country:US
Practice Address - Phone:304-521-2230
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-30
Last Update Date:2010-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2239-0413208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV=========OtherUNITED HEALTH CARE