Provider Demographics
NPI:1588625297
Name:MCKENNAN, JOHN M (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:M
Last Name:MCKENNAN
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1 OXFORD RD
Mailing Address - Street 2:
Mailing Address - City:NEW HARTFORD
Mailing Address - State:NY
Mailing Address - Zip Code:13413-2668
Mailing Address - Country:US
Mailing Address - Phone:315-624-9081
Mailing Address - Fax:315-734-9602
Practice Address - Street 1:107 BUSINESS PARK DR
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502-6399
Practice Address - Country:US
Practice Address - Phone:315-792-4666
Practice Address - Fax:315-798-1893
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2020-08-06
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY16200832085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01647929Medicaid
B81147Medicare UPIN
NY51643FMedicare ID - Type Unspecified