Provider Demographics
NPI:1417047010
Name:KENNEDY, MICHAEL S (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:S
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 1:275 W 200 N
Mailing Address - Street 2:SUITE 204
Mailing Address - City:LINDON
Mailing Address - State:UT
Mailing Address - Zip Code:84042-5009
Mailing Address - Country:US
Mailing Address - Phone:801-796-1333
Mailing Address - Fax:801-796-0625
Practice Address - Street 1:275 W 200 N
Practice Address - Street 2:SUITE 204
Practice Address - City:LINDON
Practice Address - State:UT
Practice Address - Zip Code:84042-5009
Practice Address - Country:US
Practice Address - Phone:801-796-1333
Practice Address - Fax:801-796-0625
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4994501-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine