Provider Demographics
NPI:1396919478
Name:THE DR. KENNY CLINIC, P.C.
Entity type:Organization
Organization Name:THE DR. KENNY CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:HASIJA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-764-6166
Mailing Address - Street 1:256 HAMILTON ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:01550
Mailing Address - Country:US
Mailing Address - Phone:508-764-6166
Mailing Address - Fax:
Practice Address - Street 1:256 HAMILTON ST
Practice Address - Street 2:
Practice Address - City:SOUTHBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:01550
Practice Address - Country:US
Practice Address - Phone:508-764-6166
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-18
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA35946207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9725229Medicaid
MA9725229Medicaid