Healthcare Provider Details

I. General information

NPI: 1831148931
Provider Name (Legal Business Name): KENRIC ALLEN MAYNOR M.D., M.P.H.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 08/21/2020
Certification Date: 08/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E MOUNTAIN DR
WILKES BARRE PA
18711-0027
US

IV. Provider business mailing address

129 HUCKLEBERRY DR
DURYEA PA
18642-1153
US

V. Phone/Fax

Practice location:
  • Phone: 570-826-7300
  • Fax:
Mailing address:
  • Phone: 570-826-7300
  • Fax: 570-819-5647

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberD62818
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: