Provider Demographics
NPI:1013936798
Name:KERNAN, MICHAEL TIMOTHY (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:TIMOTHY
Last Name:KERNAN
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 1:8 MORTON RD
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13214-2403
Mailing Address - Country:US
Mailing Address - Phone:315-491-4225
Mailing Address - Fax:315-284-9512
Practice Address - Street 1:8 MORTON RD STE 104
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13214-2403
Practice Address - Country:US
Practice Address - Phone:315-491-4225
Practice Address - Fax:315-663-0123
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY170712207PS0010X, 207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207PS0010XAllopathic & Osteopathic PhysiciansEmergency MedicineSports Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01075685Medicaid
NYJ400003698Medicare PIN
NYRA8169Medicare PIN
NY080104893Medicare PIN
NYB81237Medicare UPIN
NY56564FMedicare PIN