Provider Demographics
NPI:1295801173
Name:IMAN, KENNY (PAC)
Entity type:Individual
Prefix:MR
First Name:KENNY
Middle Name:
Last Name:IMAN
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4014 OAKLAND SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21804-2715
Mailing Address - Country:US
Mailing Address - Phone:410-726-1576
Mailing Address - Fax:
Practice Address - Street 1:111 DAVIS ST
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21804-5032
Practice Address - Country:US
Practice Address - Phone:410-749-4154
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-24
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0003072174400000X
DEC50000664207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDC0003072OtherP.A. LICENSE
MD1066952OtherCERTIFICATION P.A.C.
MDPA60330OtherLICENSE CONTROLLED SUBSTA
MDPA60330OtherLICENSE CONTROLLED SUBSTA
MDPA60330OtherLICENSE CONTROLLED SUBSTA
MDQ38582Medicare UPIN