Provider Demographics
NPI:1487638326
Name:KENNEDY, KATHARYN E (MD)
Entity Type:Individual
Prefix:
First Name:KATHARYN
Middle Name:E
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TARYN
Other - Middle Name:
Other - Last Name:KENNEDY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:67 N QUINSIGAMOND AVE
Mailing Address - Street 2:UNIT 15
Mailing Address - City:SHREWSBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01545-5133
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:157 UNION ST
Practice Address - Street 2:DEPARTMENT OF EMERGENCY MEDICINE
Practice Address - City:MARLBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01752-1228
Practice Address - Country:US
Practice Address - Phone:508-421-1400
Practice Address - Fax:508-421-1490
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2020-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA150663207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3160921Medicaid
MA3160921Medicaid
MAA2199501Medicare PIN