Healthcare Provider Details

I. General information

NPI: 1235443474
Provider Name (Legal Business Name): DAMIEN P KENNY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2010
Last Update Date: 03/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 W HARRISON ST 708 KELLOG
CHICAGO IL
60612-3800
US

IV. Provider business mailing address

1650 W HARRISON ST 708 KELLOG
CHICAGO IL
60612-3800
US

V. Phone/Fax

Practice location:
  • Phone: 312-942-6800
  • Fax:
Mailing address:
  • Phone: 312-942-6800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number125057887
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: