Healthcare Provider Details

I. General information

NPI: 1720021637
Provider Name (Legal Business Name): MICHAEL J. KENNELLY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 07/15/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 HARDING PL STE 3100
CHARLOTTE NC
28204-2826
US

IV. Provider business mailing address

PO BOX 19305
CHARLOTTE NC
28219-9305
US

V. Phone/Fax

Practice location:
  • Phone: 704-355-8686
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2088F0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Urology) Physician
License Number9500634
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number9500634
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: