Healthcare Provider Details

I. General information

NPI: 1487683900
Provider Name (Legal Business Name): KEVIN P. KENNALLY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 01/21/2021
Certification Date: 01/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 MAIN
SABETHA KS
66534
US

IV. Provider business mailing address

P.O. BOX 229
SABETHA KS
66534
US

V. Phone/Fax

Practice location:
  • Phone: 785-284-2141
  • Fax: 785-284-0445
Mailing address:
  • Phone: 785-284-2141
  • Fax: 785-284-0445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number04 - 19100
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: