Provider Demographics
NPI:1154391969
Name:KENNESON, MICHAEL J (DO)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
Last Name:KENNESON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:43900 GARFIELD RD
Mailing Address - Street 2:STE 222
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-1137
Mailing Address - Country:US
Mailing Address - Phone:586-286-0050
Mailing Address - Fax:586-286-0880
Practice Address - Street 1:42645 GARFIELD RD
Practice Address - Street 2:SUITE 103
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48038-5022
Practice Address - Country:US
Practice Address - Phone:586-286-0050
Practice Address - Fax:586-286-0880
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2018-06-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5101010986207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4381308Medicaid
MI4991989Medicaid
MI4381308Medicaid
MI4991989Medicaid
MIN40170025Medicare PIN
MIN40170025Medicare ID - Type UnspecifiedMEDICARE