Healthcare Provider Details

I. General information

NPI: 1902998081
Provider Name (Legal Business Name): EMMET MICHAEL KENNEY JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 04/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3201 33RD ST S
FARGO ND
58104-8823
US

IV. Provider business mailing address

3201 33RD ST S
FARGO ND
58104-8823
US

V. Phone/Fax

Practice location:
  • Phone: 701-365-4488
  • Fax: 701-365-0727
Mailing address:
  • Phone: 701-365-4488
  • Fax: 701-365-0727

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberND7174
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMN32170
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License NumberND7174
License Number StateND
# 4
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License NumberMN32170
License Number StateMN
# 5
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberND7174
License Number StateND
# 6
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberMN32170
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: