1053343111 NPI number — DEBBIE ANN KENNEDY V M.D.

Table of content: DEBBIE ANN KENNEDY V M.D. (NPI 1053343111)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053343111 NPI number — DEBBIE ANN KENNEDY V M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KENNEDY
Provider First Name:
DEBBIE
Provider Middle Name:
ANN
Provider Name Prefix Text:
Provider Name Suffix Text:
V
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053343111
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4 EXECUTIVE PARK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALBANY
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12203-3718
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-438-1434
Provider Business Mailing Address Fax Number:
518-489-1205

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4 EXECUTIVE PARK DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALBANY
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12203-3718
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-438-1434
Provider Business Practice Location Address Fax Number:
518-489-1205
Provider Enumeration Date:
07/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  176438 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 10045547 . This is a "VERMONT MEDICAID" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 19201 . This is a "MVP HEALTH PLAN" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 67314 . This is a "GHI HMO SELECT" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 00040065801 . This is a "UNIVERA HEALTH CARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 141826445 . This is a "HUMANA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: DK04611510 . This is a "EMPIRE BC/BS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 000406385003 . This is a "BS NENY" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 01274744 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10001038 . This is a "CDPHP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 20103980 . This is a "FIDELIS CARE NEW YORK" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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