Provider Demographics
NPI:1275600504
Name:KENNEDY, MICHELE (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHELE
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14312 OLD LAKE DR SW
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21502-5877
Mailing Address - Country:US
Mailing Address - Phone:301-697-3535
Mailing Address - Fax:
Practice Address - Street 1:621 KELLY RD
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502-2878
Practice Address - Country:US
Practice Address - Phone:301-722-3270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDH0065454207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVF22471Medicare UPIN