Provider Demographics
NPI:1902998081
Name:KENNEY, EMMET MICHAEL JR (MD)
Entity Type:Individual
Prefix:MR
First Name:EMMET
Middle Name:MICHAEL
Last Name:KENNEY
Suffix:JR
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 1:3201 33RD ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-8823
Mailing Address - Country:US
Mailing Address - Phone:701-365-4488
Mailing Address - Fax:701-365-0727
Practice Address - Street 1:3201 33RD ST S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-8823
Practice Address - Country:US
Practice Address - Phone:701-365-4488
Practice Address - Fax:701-365-0727
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2014-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDND71742084P0800X, 2084P0802X, 2084P0804X
MNMN321702084P0800X, 2084P0802X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN597823800Medicaid
ND22028OtherBCBS
ND18353Medicaid
MN260002086Medicare ID - Type Unspecified
ND22028OtherBCBS
MN597823800Medicaid