Healthcare Provider Details

I. General information

NPI: 1073556528
Provider Name (Legal Business Name): MICHAEL G. MCKENNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 11/30/2023
Certification Date: 11/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 S GULPH RD
KING OF PRUSSIA PA
19406-3112
US

IV. Provider business mailing address

140 W GERMANTOWN PIKE STE 250
PLYMOUTH MEETING PA
19462-1421
US

V. Phone/Fax

Practice location:
  • Phone: 610-382-5900
  • Fax: 610-382-5919
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number25MA060033
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: