Provider Demographics
NPI:1023000312
Name:KENNEDY, ROBERT BACH (OD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:BACH
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1790 LEXINGTON AVE N
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-6167
Mailing Address - Country:US
Mailing Address - Phone:651-488-6771
Mailing Address - Fax:651-488-5576
Practice Address - Street 1:1790 LEXINGTON AVE N
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-6167
Practice Address - Country:US
Practice Address - Phone:651-488-6771
Practice Address - Fax:651-488-5576
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLD1699000152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T90942Medicare UPIN