Provider Demographics
NPI:1952397051
Name:MCKENNA, PATRICK H (MD)
Entity Type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:H
Last Name:MCKENNA
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 1:8201 E RIVERSIDE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61114-2300
Mailing Address - Country:US
Mailing Address - Phone:815-971-7255
Mailing Address - Fax:815-971-9955
Practice Address - Street 1:8201 E RIVERSIDE BLVD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61114-2300
Practice Address - Country:US
Practice Address - Phone:815-971-7255
Practice Address - Fax:815-971-9955
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2020-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036103859208800000X, 2088P0231X
WI573352088P0231X, 208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2088P0231XAllopathic & Osteopathic PhysiciansUrologyPediatric Urology
No208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1952397051Medicaid
IL036103859Medicaid
ILL82836Medicare PIN
IL256510Medicare PIN