Provider Demographics
NPI:1376537001
Name:KENNEDY, STEVEN CLARK (MD)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:CLARK
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4700 BATTLEFIELD PKWY STE 220
Mailing Address - Street 2:
Mailing Address - City:RINGGOLD
Mailing Address - State:GA
Mailing Address - Zip Code:30736-5168
Mailing Address - Country:US
Mailing Address - Phone:423-698-8692
Mailing Address - Fax:423-624-7813
Practice Address - Street 1:4700 BATTLEFIELD PKWY STE 220
Practice Address - Street 2:
Practice Address - City:RINGGOLD
Practice Address - State:GA
Practice Address - Zip Code:30736-5168
Practice Address - Country:US
Practice Address - Phone:423-698-8692
Practice Address - Fax:423-624-7813
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2022-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN37194208600000X
GA072631208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA694719009EMedicaid
GA694719009FMedicaid
8381476OtherCIGNA
TN3880719Medicaid
TN0184OtherJDH
GA694719009CMedicaid
3880711Medicare PIN
4087653OtherBCBS OF TN