Healthcare Provider Details

I. General information

NPI: 1114283371
Provider Name (Legal Business Name): KONRAD SPENCER KENNINGTON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2012
Last Update Date: 05/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1034 N 500 W
PROVO UT
84604
US

IV. Provider business mailing address

4308 N CHESTNUT OAK DR
LEHI UT
84043-4985
US

V. Phone/Fax

Practice location:
  • Phone: 801-357-7850
  • Fax:
Mailing address:
  • Phone: 801-821-7899
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number8771575-1205
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number8771575-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: