1114115045 NPI number — STEPHEN KENNEDY DO LLC

Table of content: (NPI 1114115045)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114115045 NPI number — STEPHEN KENNEDY DO LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STEPHEN KENNEDY DO LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1114115045
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/10/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1415 LINCOLN WAY W
Provider Second Line Business Mailing Address:
SUITE O
Provider Business Mailing Address City Name:
OSCEOLA
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46561-2062
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-674-6499
Provider Business Mailing Address Fax Number:
574-674-6490

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1415 LINCOLN WAY W
Provider Second Line Business Practice Location Address:
SUITE O
Provider Business Practice Location Address City Name:
OSCEOLA
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46561-2062
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-674-6499
Provider Business Practice Location Address Fax Number:
574-674-6490
Provider Enumeration Date:
10/04/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KENNEDY
Authorized Official First Name:
STEPHEN
Authorized Official Middle Name:
D
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
574-255-4733

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  02001650A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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