Basic Information
| Provider Information | |||||||||
| NPI: | 1316172513 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MUNNERLYN | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | ARCEDRICK | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1040 SIERRA DR STE 400 | ||||||||
| Address2: | |||||||||
| City: | GREENWOOD | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461437241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175284800 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 800 W CENTRAL RD | ||||||||
| Address2: | |||||||||
| City: | ARLINGTON HEIGHTS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600052349 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8476185671 | ||||||||
| FaxNumber: | 8476185669 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2009 | ||||||||
| LastUpdateDate: | 11/09/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 01076175A | IN | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | 036133586 | IL | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | 056609 | CT | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | 80701 | GA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 1316172513 | 05 | WI | MEDICAID |