Healthcare Provider Details

I. General information

NPI: 1518932276
Provider Name (Legal Business Name): BRIAN P MCKENNA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2006
Last Update Date: 12/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001 EXPRESSWAY DR N SUITE 116
ISLANDIA NY
11749-5301
US

IV. Provider business mailing address

3001 EXPRESSWAY DR N SUITE 116
ISLANDIA NY
11749-5301
US

V. Phone/Fax

Practice location:
  • Phone: 631-292-6747
  • Fax: 631-292-6767
Mailing address:
  • Phone: 631-292-6747
  • Fax: 631-292-6767

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number181486
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number181486
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number181486
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: