Provider Demographics
NPI:1700878147
Name:KENNEN, WILLIAM JR (DO)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:KENNEN
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 HIGHWAY 61
Mailing Address - Street 2:MOC SOUTH, SUITE 210
Mailing Address - City:FESTUS
Mailing Address - State:MO
Mailing Address - Zip Code:63028-4100
Mailing Address - Country:US
Mailing Address - Phone:636-933-8050
Mailing Address - Fax:636-933-8075
Practice Address - Street 1:1400 HIGHWAY 61
Practice Address - Street 2:MOC SOUTH, SUITE 210
Practice Address - City:FESTUS
Practice Address - State:MO
Practice Address - Zip Code:63028-4100
Practice Address - Country:US
Practice Address - Phone:636-933-8050
Practice Address - Fax:646-933-8075
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010002299207X00000X
PAOS005811L207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1700878147Medicaid
189166Medicare PIN
MO1700878147Medicaid