Provider Demographics
NPI:1003010984
Name:KENNEDY, STEPHEN ROGERS (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:ROGERS
Last Name:KENNEDY
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 1:501 6TH AVE S
Mailing Address - Street 2:BOX 6941
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-4634
Mailing Address - Country:US
Mailing Address - Phone:727-767-4429
Mailing Address - Fax:727-767-4970
Practice Address - Street 1:501 6TH AVE S
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-4634
Practice Address - Country:US
Practice Address - Phone:727-767-4243
Practice Address - Fax:727-767-8612
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME98966208000000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL9072063OtherAETNA
FL309196OtherAVMED
FL81039OtherBLUE CROSS/BLUE SHIELD
FL512248OtherSTAYWELL/HEALTHEASE
FL278329100Medicaid