Provider Demographics
NPI:1548445307
Name:KENLY, MICHAEL SCOTT (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:SCOTT
Last Name:KENLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:511 BATH ST
Mailing Address - Street 2:
Mailing Address - City:SANTA BARBARA
Mailing Address - State:CA
Mailing Address - Zip Code:93101-3403
Mailing Address - Country:US
Mailing Address - Phone:805-963-9377
Mailing Address - Fax:805-962-2154
Practice Address - Street 1:511 BATH ST
Practice Address - Street 2:
Practice Address - City:SANTA BARBARA
Practice Address - State:CA
Practice Address - Zip Code:93101-3403
Practice Address - Country:US
Practice Address - Phone:805-963-9377
Practice Address - Fax:805-962-2154
Is Sole Proprietor?:No
Enumeration Date:2007-12-29
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA62730208100000X
CAA113590208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEJ158ZOtherSOUTHERN MEDICARE PTAN
CAEJ158YOtherNORTHERN MEDICARE PTAN
CAA113590OtherDCA MEDICAL LICENSE