Provider Demographics
NPI:1508078445
Name:KENNEDY CLINIC PLLC
Entity Type:Organization
Organization Name:KENNEDY CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HOWARD
Authorized Official - Middle Name:M
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:423-432-3130
Mailing Address - Street 1:4957 SWINYAR DR
Mailing Address - Street 2:SUITE 109
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363
Mailing Address - Country:US
Mailing Address - Phone:423-432-3130
Mailing Address - Fax:423-396-9508
Practice Address - Street 1:4957 SWINYAR DR STE 109
Practice Address - Street 2:
Practice Address - City:OOLTEWAH
Practice Address - State:TN
Practice Address - Zip Code:37363-2205
Practice Address - Country:US
Practice Address - Phone:423-396-9893
Practice Address - Fax:423-396-9508
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1942280052OtherKENNEDY NPI#
TN4136940OtherKENNEDY BCBS
TN413276426OtherKENNEDY SS#
TN1942280052OtherKENNEDY NPI#
TN1902844772OtherRIMER NPI#
TN=========OtherRIMER EIN#
TN=========OtherKENNEDY EIN#
TN=========OtherRIMER EIN#
TN1902844772OtherRIMER NPI#