Individual
DANIEL T. MCKENNA
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
2845 GREENBRIER RD STE 230, GREEN BAY, WI 54311-6519
(920) 288-8250
(920) 288-8255
Mailing address
164 N BROADWAY, GREEN BAY, WI 54303-2728
Taxonomy
Speciality
Code
Description
License number
State
208600000X
Surgery Physician
Primary
01066803A
IN
208600000X
Surgery Physician
48301
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000624111
ANTHEM PIN
IN
05
—
200943060
—
IN
Enumeration date
05/05/2006
Last updated
03/28/2016
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