Healthcare Provider Details

I. General information

NPI: 1790761534
Provider Name (Legal Business Name): L THOMAS KENNEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2005
Last Update Date: 11/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1716 HARTFORD ST
LAFAYETTE IN
47904-2173
US

IV. Provider business mailing address

1716 HARTFORD ST
LAFAYETTE IN
47904-2173
US

V. Phone/Fax

Practice location:
  • Phone: 765-742-1567
  • Fax: 765-429-2700
Mailing address:
  • Phone: 765-742-1567
  • Fax: 765-429-2700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35030307
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: