MEDICARE: GREGORY G KENIEN MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RC0000X	Cardiovascular Disease Physician	168165	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1770582843
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GREGORY G KENIEN MD

Provider Business Mailing Address
First Line	:	510 TOWNE DR
Second Line	:
City	:	FAYETTEVILLE
State	:	NY
Zip	:	13066-1331
Country	:	US
Telephone Number	:	315-663-0500
Fax Number	:	315-663-0514

Provider Business Practice Location Address
First Line	:	510 TOWNE DR
Second Line	:
City	:	FAYETTEVILLE
State	:	NY
Zip	:	13066-1331
Country	:	US
Telephone Number	:	315-663-0500
Fax Number	:	315-663-0514

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/20/2005
Last Update Date	:	09/27/2019

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