Provider Demographics
NPI:1235152588
Name:KENNEDY, CHARLOTTE J (MD PH D)
Entity Type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:J
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:MD PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4921 PARKVIEW PL STE 5G
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1032
Mailing Address - Country:US
Mailing Address - Phone:314-747-1970
Mailing Address - Fax:314-747-1970
Practice Address - Street 1:4921 PARKVIEW PL STE 5G
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1032
Practice Address - Country:US
Practice Address - Phone:314-747-1970
Practice Address - Fax:314-747-1972
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO100880207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G73839Medicare UPIN