Healthcare Provider Details

I. General information

NPI: 1386859775
Provider Name (Legal Business Name): JEREMY S KENDRA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2007
Last Update Date: 06/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 HARRINGTON ST
MOUNT CLEMENS MI
48043-2920
US

IV. Provider business mailing address

3601 W 13 MILE RD
ROYAL OAK MI
48073-6712
US

V. Phone/Fax

Practice location:
  • Phone: 586-493-8098
  • Fax: 586-493-8706
Mailing address:
  • Phone: 248-551-0424
  • Fax: 248-551-5426

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number4301084369
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: