Provider Demographics
NPI:1538140744
Name:KENNEDY, COLLEEN M (DO)
Entity Type:Individual
Prefix:DR
First Name:COLLEEN
Middle Name:M
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 BARCLAY CIRCLE
Mailing Address - Street 2:SUITE 225
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48307
Mailing Address - Country:US
Mailing Address - Phone:248-299-1892
Mailing Address - Fax:248-299-2396
Practice Address - Street 1:75 BARCLAY CIR
Practice Address - Street 2:SUITE 225
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48307-5820
Practice Address - Country:US
Practice Address - Phone:248-299-1892
Practice Address - Fax:248-299-2396
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2011-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101012334207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N22720OtherMEDICARE TYPE UNSPECIFIED
G58126Medicare UPIN