Provider Demographics
NPI:1417111790
Name:KENNEDY, MICHAEL GEORGE (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:GEORGE
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:363 S RANDALL RD
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60123-5526
Mailing Address - Country:US
Mailing Address - Phone:847-888-1555
Mailing Address - Fax:
Practice Address - Street 1:363 S RANDALL RD
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-5526
Practice Address - Country:US
Practice Address - Phone:847-888-1555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-15
Last Update Date:2012-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046010127152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36-3546473OtherTAX ID
IL1508088683OtherGROUP NPI FOR BCBS
IL4515286OtherBCBS
IL1891842464OtherOTHER NPI
IL36-3546473OtherTAX ID
IL799670Medicare Oscar/Certification