Provider Demographics
NPI:1225102304
Name:KENNEDY, JAMES A (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:A
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:PO BOX 5010
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58702-5010
Mailing Address - Country:US
Mailing Address - Phone:701-857-5650
Mailing Address - Fax:701-857-5031
Practice Address - Street 1:1321 W DAKOTA PKWY
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:ND
Practice Address - Zip Code:58801-3807
Practice Address - Country:US
Practice Address - Phone:701-572-7711
Practice Address - Fax:701-572-2283
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND7410207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1452078Medicaid
G32223Medicare UPIN
NDN714754Medicare PIN