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General NPI Number Information
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NPI Number | 1871579847
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Entity Type | Individual
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Provider Name | GREGORY A KENNEBECK MD
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Gender | Male
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Dates
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Enumeration Date | 12/21/2005
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Last Update Date | 05/31/2013
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Provider Practice Location Address
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Address Line | 101 BODIN CIR
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City | TRAVIS AFB
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State | CA
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Zip | 94535-1809
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Country | US
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Telephone | 707-423-1110
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Fax |
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Provider Business Mailing Address
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Address Line | 2312 FAR HILLS AVE # 147
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City | DAYTON
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State | OH
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Zip | 45419-1512
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Country | US
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Telephone | 937-938-3329
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number | A63038
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | A63038
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License Number State | CA
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