Healthcare Provider Details

I. General information

NPI: 1144252016
Provider Name (Legal Business Name): DOUGLAS R KENNEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

603 E GAINES DR
CLINTON MO
64735-3205
US

IV. Provider business mailing address

603 E GAINES DR
CLINTON MO
64735-3205
US

V. Phone/Fax

Practice location:
  • Phone: 660-885-8141
  • Fax: 660-885-5815
Mailing address:
  • Phone: 660-885-8141
  • Fax: 660-885-5815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35974
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: