Provider Demographics
NPI:1760465348
Name:KENYON, PAUL SCOTT (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:SCOTT
Last Name:KENYON
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 1:150 S EAST AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-2412
Mailing Address - Country:US
Mailing Address - Phone:517-787-6924
Mailing Address - Fax:517-787-8335
Practice Address - Street 1:150 S EAST AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-2412
Practice Address - Country:US
Practice Address - Phone:517-787-6924
Practice Address - Fax:517-787-8335
Is Sole Proprietor?:No
Enumeration Date:2005-11-28
Last Update Date:2014-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI49140207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0380337OtherBCBSM
MI2572436Medicaid
MIE90776Medicare UPIN
0481370001Medicare NSC