Healthcare Provider Details

I. General information

NPI: 1992760979
Provider Name (Legal Business Name): KENNETH M KERNEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 07/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 TOWN CENTER DR SUITE 101
TROY MI
48084-1744
US

IV. Provider business mailing address

20952 E 12 MILE RD SUITE 200
ST CLAIR SHORES MI
48081-3200
US

V. Phone/Fax

Practice location:
  • Phone: 248-740-0670
  • Fax: 248-740-0668
Mailing address:
  • Phone: 586-771-4820
  • Fax: 586-771-6620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number4301062269
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: