Provider Demographics
NPI:1659321297
Name:KENNY, FREDRICK I (MD)
Entity Type:Individual
Prefix:DR
First Name:FREDRICK
Middle Name:I
Last Name:KENNY
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 1:3020 E CAMELBACK RD
Mailing Address - Street 2:STE. 200
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-5095
Mailing Address - Country:US
Mailing Address - Phone:602-264-9100
Mailing Address - Fax:602-264-9101
Practice Address - Street 1:349 E CORONADO RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85004-1525
Practice Address - Country:US
Practice Address - Phone:602-266-5678
Practice Address - Fax:602-264-5646
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ16863207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ67730OtherMEDICARE LEGACY
AZ317047OtherGROUP MEDICAID NUMBER
AZ120390OtherGROUP MEDICARE NUMBER
AZZ67730OtherMEDICARE LEGACY
AZ317047OtherGROUP MEDICAID NUMBER