Provider Demographics
NPI:1205123361
Name:KENWORTHY, MARY ELLEN (DO)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:ELLEN
Last Name:KENWORTHY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:MISS
Other - First Name:MARY
Other - Middle Name:ELLEN
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:50 NORTH PERRY STREET
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48342
Mailing Address - Country:US
Mailing Address - Phone:248-338-5393
Mailing Address - Fax:248-338-5567
Practice Address - Street 1:50 NORTH PERRY STREET
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48342
Practice Address - Country:US
Practice Address - Phone:276-223-8350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-08
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3444207P00000X
VA0102204478207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine