Provider Demographics
NPI:1295820264
Name:KENNEDY, BRIAN LEE (PA)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:LEE
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4848 MCLEOD DR E
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48604-2839
Mailing Address - Country:US
Mailing Address - Phone:989-793-6200
Mailing Address - Fax:989-793-9997
Practice Address - Street 1:4848 MCLEOD DR E
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48604-2839
Practice Address - Country:US
Practice Address - Phone:989-793-6200
Practice Address - Fax:989-793-9997
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2010-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003698363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0G36045OtherMEDICARE NUMBER