Provider Demographics
NPI:1003975442
Name:KENNEDY MEDICAL SERVICE CORP
Entity Type:Organization
Organization Name:KENNEDY MEDICAL SERVICE CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LOFTON
Authorized Official - Middle Name:
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:312-504-0438
Mailing Address - Street 1:175 E DELAWARE PL
Mailing Address - Street 2:SUITE 5024
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-1756
Mailing Address - Country:US
Mailing Address - Phone:312-504-0438
Mailing Address - Fax:
Practice Address - Street 1:175 E DELAWARE PL
Practice Address - Street 2:SUITE 5024
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-1756
Practice Address - Country:US
Practice Address - Phone:312-504-0438
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL212220Medicare ID - Type Unspecified