Provider Demographics
NPI:1255352597
Name:FENNELLY, KEVIN PATRICK (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:PATRICK
Last Name:FENNELLY
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:NIH NHLBI CARDIOVASCULAR BR
Mailing Address - Street 2:10 CENTER DRIVE, BLDG 10, ROOM 6-3152
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20892-0001
Mailing Address - Country:US
Mailing Address - Phone:301-827-0511
Mailing Address - Fax:301-451-7093
Practice Address - Street 1:NIH NHLBI CARDIOVASCULAR BR
Practice Address - Street 2:10 CENTER DRIVE, BLDG 10, ROOM 6-3152
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20892-0001
Practice Address - Country:US
Practice Address - Phone:301-827-0511
Practice Address - Fax:301-451-7093
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2015-12-16
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Provider Licenses
StateLicense IDTaxonomies
NJ25MA07311800207RP1001X, 2083P0500X
FLME106064207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ5650607Medicaid
FL001760100Medicaid
NJ084353Medicare PIN
NJ5650607Medicaid
FLCT935ZMedicare PIN