Provider Demographics
NPI:1033145560
Name:KAREN E KENNEDY MD PA
Entity Type:Organization
Organization Name:KAREN E KENNEDY MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:E
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-916-7766
Mailing Address - Street 1:1118 GULF BREEZE PKWY
Mailing Address - Street 2:STE. 201
Mailing Address - City:GULF BREEZE
Mailing Address - State:FL
Mailing Address - Zip Code:32561-7800
Mailing Address - Country:US
Mailing Address - Phone:850-916-7766
Mailing Address - Fax:850-916-5144
Practice Address - Street 1:1118 GULF BREEZE PKWY
Practice Address - Street 2:STE. 201
Practice Address - City:GULF BREEZE
Practice Address - State:FL
Practice Address - Zip Code:32561-7800
Practice Address - Country:US
Practice Address - Phone:850-916-7766
Practice Address - Fax:850-916-5144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-25
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME75325207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL10D0270871OtherCMS CLIA
FL261713700Medicaid
FLDG1413OtherRR MEDICARE GP#
FL0701115OtherUNITED HEALTH CARE
FL59041231KENOtherBS ALABAMA
FL58754OtherBS FLORIDA
FLAD696OtherMEDICARE GRP EFF 10-2-06
FL7856118OtherAETNA
FL21149353644OtherBEECH STREET
FL0701115OtherUNITED HEALTH CARE