Provider Demographics
NPI:1215029897
Name:KENNEDY, RICHARD D (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:D
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 1:3024 BUSINESS PARK CIR
Mailing Address - Street 2:
Mailing Address - City:GOODLETTSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37072-3132
Mailing Address - Country:US
Mailing Address - Phone:615-239-2018
Mailing Address - Fax:
Practice Address - Street 1:1609 ROSEWOOD DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:TN
Practice Address - Zip Code:38401-6420
Practice Address - Country:US
Practice Address - Phone:931-388-8802
Practice Address - Fax:931-490-2292
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN34124207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1512603Medicaid
TN3850826Medicaid
TN38508261Medicaid
TN3710089Medicaid
TN4021933OtherBCBSTN
TN38508261Medicaid
TN3850826Medicaid
TN3710089Medicare PIN
TN4021933OtherBCBSTN
TNCE0561Medicare PIN
TNH21382Medicare UPIN