Provider Demographics
NPI:1245213412
Name:KENNEDY, REBECCA SMITH (MD)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:SMITH
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 1:1331 N ELM ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27401-6302
Mailing Address - Country:US
Mailing Address - Phone:336-274-9617
Mailing Address - Fax:336-482-2177
Practice Address - Street 1:1331 N ELM ST
Practice Address - Street 2:SUITE 200
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-6302
Practice Address - Country:US
Practice Address - Phone:336-274-9617
Practice Address - Fax:336-482-2177
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2014-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC336952085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1082OtherPARTNERS
NC48458OtherBLUE CROSS BLUE SHIELD
NC70510OtherMEDCOST
NC30005071OtherRAILROAD MEDICARE
NC8948458Medicaid
NC48458OtherBLUE CROSS BLUE SHIELD
NC8948458Medicaid