Healthcare Provider Details

I. General information

NPI: 1992743637
Provider Name (Legal Business Name): MARK T. KINNE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 10/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7905 CALUMET AVE FRANCISCAN HAMMOND CLINIC LLC
MUNSTER IN
46321-1215
US

IV. Provider business mailing address

7905 CALUMET AVE FRANCISCAN HAMMOND CLINIC LLC
MUNSTER IN
46321-1215
US

V. Phone/Fax

Practice location:
  • Phone: 219-836-7214
  • Fax: 219-365-9037
Mailing address:
  • Phone: 219-836-7214
  • Fax: 219-365-9037

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01028626A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: