Provider Demographics
NPI:1548260573
Name:HENNON, KIMBERLY ANN (MD)
Entity type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:ANN
Last Name:HENNON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 E NORTH AVE
Mailing Address - Street 2:AGH EMERGENCY ASSOCS
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15212
Mailing Address - Country:US
Mailing Address - Phone:412-359-4138
Mailing Address - Fax:412-359-8874
Practice Address - Street 1:100 MEDICAL BLVD
Practice Address - Street 2:CANONSBURG HOSPITAL
Practice Address - City:CANONSBURG
Practice Address - State:PA
Practice Address - Zip Code:15317
Practice Address - Country:US
Practice Address - Phone:724-745-3077
Practice Address - Fax:724-746-8579
Is Sole Proprietor?:No
Enumeration Date:2005-08-01
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD057343L207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1809907000Medicaid
OH2235861Medicaid
PA0015659650002Medicaid
PA833678NJRMedicare PIN
PA0015659650002Medicaid
WV1809907000Medicaid
PACG2169Medicare PIN
PAG22316Medicare UPIN
PACG2176Medicare PIN