Provider Demographics
NPI:1023178522
Name:KENNEDY, JOHN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
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 1:100 N ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-4903
Mailing Address - Country:US
Mailing Address - Phone:570-271-6621
Mailing Address - Fax:
Practice Address - Street 1:100 N ACADEMY AVE
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:PA
Practice Address - Zip Code:17822-4903
Practice Address - Country:US
Practice Address - Phone:570-271-6621
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2014-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA67585207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ679766Medicare UPIN