Provider Demographics
NPI:1386694354
Name:KENNY, THOMAS J IV (MD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:J
Last Name:KENNY
Suffix:IV
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:THOMAS
Other - Middle Name:J
Other - Last Name:KENNY
Other - Suffix:IV
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:956 PEBBLE BEACH DR
Mailing Address - Street 2:
Mailing Address - City:DAKOTA DUNES
Mailing Address - State:SD
Mailing Address - Zip Code:57049-5107
Mailing Address - Country:US
Mailing Address - Phone:605-422-1080
Mailing Address - Fax:605-217-2948
Practice Address - Street 1:101 TOWER RD
Practice Address - Street 2:SUITE 120
Practice Address - City:DAKOTA DUNES
Practice Address - State:SD
Practice Address - Zip Code:57049-5007
Practice Address - Country:US
Practice Address - Phone:605-217-4320
Practice Address - Fax:605-217-2948
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2012-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA34004207Y00000X
SD5111207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA2239616Medicaid
SD7701502Medicaid
SD7701503Medicaid
IA37196OtherBLUE CROSS PROVIDER NUM
NE10025206800Medicaid
NE100251553 00Medicaid
IA1239616Medicaid
IA37777Other2ND BCBS PROVIDER NUM
SD7701502Medicaid
IA37777Other2ND BCBS PROVIDER NUM
SD7701503Medicaid