Provider Demographics
NPI:1952496069
Name:MCKENNA, PETER JAMES (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:JAMES
Last Name:MCKENNA
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 1:10577 MONTGOMERY RD
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45242-4451
Mailing Address - Country:US
Mailing Address - Phone:513-793-5772
Mailing Address - Fax:513-792-5384
Practice Address - Street 1:10577 MONTGOMERY RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45242-4451
Practice Address - Country:US
Practice Address - Phone:513-793-5772
Practice Address - Fax:513-792-5384
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-05-7586-M174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0884940Medicaid
OHMC0715401Medicare ID - Type Unspecified
OH0884940Medicaid