Provider Demographics
NPI:1124550009
Name:KENNEDY, GREGORY THOMAS
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:THOMAS
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2215 SAINT ALBANS ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19146-1714
Mailing Address - Country:US
Mailing Address - Phone:904-699-3989
Mailing Address - Fax:
Practice Address - Street 1:3400 SPRUCE STREET, 4 MALONEY BUILDING
Practice Address - Street 2:UPHS GENERAL SURGERY RESIDENCY TRAINING PROGRAM
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4238
Practice Address - Country:US
Practice Address - Phone:904-699-3989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-30
Last Update Date:2017-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program