MEDICARE: KEVIN X MCKENNAN MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207YX0901X	Otology & Neurotology Physician	G40176	CA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	040003543	OTHER	CA	RR MEDICARE PIN

General Provider Information

NPI Number	:	1356344022
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEVIN X MCKENNAN MD

Provider Business Mailing Address
First Line	:	1111 EXPOSITION BLVD
Second Line	:	BLDG 700
City	:	SACRAMENTO
State	:	CA
Zip	:	95815-4300
Country	:	US
Telephone Number	:	916-736-3399
Fax Number	:	916-233-4171

Provider Business Practice Location Address
First Line	:	1111 EXPOSITION BLVD BLDG 700
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95815-4314
Country	:	US
Telephone Number	:	916-736-3408
Fax Number	:	916-233-4171

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/24/2005
Last Update Date	:	10/04/2018

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