Provider Demographics
NPI:1316172513
Name:MUNNERLYN, KENNETH ARCEDRICK (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:ARCEDRICK
Last Name:MUNNERLYN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2623 N CLARK ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-1524
Mailing Address - Country:US
Mailing Address - Phone:312-722-6977
Mailing Address - Fax:
Practice Address - Street 1:2623 N CLARK ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-1524
Practice Address - Country:US
Practice Address - Phone:312-722-6977
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-18
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361335862084N0400X
IN01076175A2084N0400X
GA807012084N0400X
CT0566092084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1316172513Medicaid