Provider Demographics
NPI:1003047267
Name:KENNEDY, RAELENE D (MD)
Entity Type:Individual
Prefix:
First Name:RAELENE
Middle Name:D
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1725 W HARRISON ST STE 810
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3863
Mailing Address - Country:US
Mailing Address - Phone:312-942-5500
Mailing Address - Fax:
Practice Address - Street 1:1725 W HARRISON ST STE 810
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612
Practice Address - Country:US
Practice Address - Phone:312-942-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-05
Last Update Date:2019-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-1485732086S0102X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN020003099Medicare PIN