Healthcare Provider Details

I. General information

NPI: 1831603596
Provider Name (Legal Business Name): KENNETH MD PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2017
Last Update Date: 12/27/2019
Certification Date: 12/27/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4100 RIVER RD
EAST CHINA MI
48054-2909
US

IV. Provider business mailing address

6383 GLYNDEBOURNE DR
TROY MI
48098-2214
US

V. Phone/Fax

Practice location:
  • Phone: 810-329-7111
  • Fax:
Mailing address:
  • Phone: 586-960-5358
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301100071
License Number StateMI

VIII. Authorized Official

Name: LYNN JUSTUSSON
Title or Position: VP
Credential:
Phone: 248-743-0396