Provider Demographics
NPI:1831603596
Name:KENNETH MD PLC
Entity type:Organization
Organization Name:KENNETH MD PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:JUSTUSSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-743-0396
Mailing Address - Street 1:6383 GLYNDEBOURNE DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48098-2214
Mailing Address - Country:US
Mailing Address - Phone:586-960-5358
Mailing Address - Fax:
Practice Address - Street 1:4100 RIVER RD
Practice Address - Street 2:
Practice Address - City:EAST CHINA
Practice Address - State:MI
Practice Address - Zip Code:48054-2909
Practice Address - Country:US
Practice Address - Phone:810-329-7111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-16
Last Update Date:2019-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301100071207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301100071OtherSTATE LICENSE