Provider Demographics
NPI:1255323291
Name:KENNEDY, CAROL A (MD)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:A
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 1:1620 BRIGHAM DR STE 240
Mailing Address - Street 2:
Mailing Address - City:PERRYSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43551-7124
Mailing Address - Country:US
Mailing Address - Phone:419-872-7700
Mailing Address - Fax:419-874-0196
Practice Address - Street 1:1601 BRIGHAM DR
Practice Address - Street 2:SUITE 200
Practice Address - City:PERRYSBURG
Practice Address - State:OH
Practice Address - Zip Code:43551-7114
Practice Address - Country:US
Practice Address - Phone:419-872-7700
Practice Address - Fax:419-874-0196
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35057194208000000X
OH34057194208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH00625OtherPHC
OH000000141232OtherANTHEM
OH0634374OtherAETNA
OH12-01218OtherUHC
OH0741344Medicaid