Healthcare Provider Details

I. General information

NPI: 1639264146
Provider Name (Legal Business Name): MICHAEL E KILKENNY MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

514 HENDRICKS STREET
WAYNE WV
25570-0729
US

IV. Provider business mailing address

PO BOX 729
WAYNE WV
25570-0729
US

V. Phone/Fax

Practice location:
  • Phone: 304-272-3005
  • Fax: 304-272-3335
Mailing address:
  • Phone: 304-272-3005
  • Fax: 304-272-3335

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number13536
License Number StateWV

VIII. Authorized Official

Name: DR. MICHAEL E KILKENNY
Title or Position: OWNER
Credential: M.D.
Phone: 304-272-3005