Provider Demographics
NPI:1528401056
Name:GENE S. KENNEDY M.D. P.C.
Entity Type:Organization
Organization Name:GENE S. KENNEDY M.D. P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREASURER/SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:MARION
Authorized Official - Middle Name:ELAINE
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-634-2651
Mailing Address - Street 1:PO BOX 20647
Mailing Address - Street 2:
Mailing Address - City:ST SIMONS ISLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31522-0247
Mailing Address - Country:US
Mailing Address - Phone:912-634-2651
Mailing Address - Fax:912-634-2653
Practice Address - Street 1:101 HERON WALK
Practice Address - Street 2:
Practice Address - City:ST SIMONS ISLAND
Practice Address - State:GA
Practice Address - Zip Code:31522-2585
Practice Address - Country:US
Practice Address - Phone:912-634-2651
Practice Address - Fax:912-634-2653
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-15
Last Update Date:2013-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA050645207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAF66222Medicare UPIN