Provider Demographics
NPI:1245206366
Name:KENNEDY, JOANNE (MD)
Entity Type:Individual
Prefix:
First Name:JOANNE
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:744 1ST ST
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-6840
Mailing Address - Country:US
Mailing Address - Phone:478-633-7600
Mailing Address - Fax:478-633-2175
Practice Address - Street 1:744 1ST ST
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-6840
Practice Address - Country:US
Practice Address - Phone:478-633-7600
Practice Address - Fax:478-633-2175
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2012-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA056880208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA131159704AMedicaid
GAE62058Medicare UPIN
GA131159704AMedicaid