Provider Demographics
NPI:1730159765
Name:KILKENNY, MICHAEL EUGENE (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:EUGENE
Last Name:KILKENNY
Suffix:
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:PO BOX 1249
Mailing Address - Street 2:
Mailing Address - City:CEREDO
Mailing Address - State:WV
Mailing Address - Zip Code:25507-1249
Mailing Address - Country:US
Mailing Address - Phone:304-453-3050
Mailing Address - Fax:
Practice Address - Street 1:US 60 AT 4TH STREET
Practice Address - Street 2:STORE ROOM #6
Practice Address - City:CEREDO
Practice Address - State:WV
Practice Address - Zip Code:25507-1249
Practice Address - Country:US
Practice Address - Phone:304-453-3050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-24
Last Update Date:2012-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV13536207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0050099000Medicaid
WV0050099000Medicaid
WVA72235Medicare UPIN