Provider Demographics
NPI:1073793311
Name:KENNEDY, BURTON LEE (MD)
Entity Type:Individual
Prefix:
First Name:BURTON
Middle Name:LEE
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 1:400 SHADOWLINE DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:BOONE
Mailing Address - State:NC
Mailing Address - Zip Code:28607-5089
Mailing Address - Country:US
Mailing Address - Phone:828-262-0600
Mailing Address - Fax:
Practice Address - Street 1:400 SHADOWLINE DR
Practice Address - Street 2:SUITE 202
Practice Address - City:BOONE
Practice Address - State:NC
Practice Address - Zip Code:28607-5089
Practice Address - Country:US
Practice Address - Phone:828-262-0600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-04
Last Update Date:2010-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2009-007222084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC52164BMedicare UPIN