Provider Demographics
NPI:1770582843
Name:KENIEN, GREGORY G (MD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:G
Last Name:KENIEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 TOWNE DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13066-1331
Mailing Address - Country:US
Mailing Address - Phone:315-663-0500
Mailing Address - Fax:315-663-0514
Practice Address - Street 1:510 TOWNE DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13066-1331
Practice Address - Country:US
Practice Address - Phone:315-663-0500
Practice Address - Fax:315-663-0514
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2019-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY168165207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00984932Medicaid
51137TMedicare PIN
NYB82330Medicare UPIN
060069756Medicare PIN
NY00984932Medicaid
DD1996Medicare PIN
060023697Medicare PIN