Healthcare Provider Details

I. General information

NPI: 1174591556
Provider Name (Legal Business Name): KENNETH BRUCE QUENNEVILLE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2006
Last Update Date: 10/16/2023
Certification Date: 10/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12000 COUNTY ROAD 801
MEMPHIS MO
63555-2024
US

IV. Provider business mailing address

12000 COUNTY ROAD 801
MEMPHIS MO
63555-2024
US

V. Phone/Fax

Practice location:
  • Phone: 660-988-1296
  • Fax:
Mailing address:
  • Phone: 660-988-1296
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number39876
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number2009029477
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2009029477
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: