Provider Demographics
NPI:1477549418
Name:KENNEDY, PHILIP A (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:A
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 1:698 DEEP WOODS DR
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:OH
Mailing Address - Zip Code:44202-9761
Mailing Address - Country:US
Mailing Address - Phone:330-807-6726
Mailing Address - Fax:
Practice Address - Street 1:698 DEEP WOODS DR
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:OH
Practice Address - Zip Code:44202-9761
Practice Address - Country:US
Practice Address - Phone:330-807-6726
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-26
Last Update Date:2013-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35044796K207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0428273Medicaid
OH0428273Medicaid
OHB7757Medicare UPIN
OHKE0517781Medicare ID - Type Unspecified