Healthcare Provider Details

I. General information

NPI: 1790153864
Provider Name (Legal Business Name): DAVID KENNEY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2015
Last Update Date: 09/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 HOBART ST
CADILLAC MI
49601-2331
US

IV. Provider business mailing address

12786 DUNDEE DR
GRAND LEDGE MI
48837-8956
US

V. Phone/Fax

Practice location:
  • Phone: 231-876-7200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601007504
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: