Provider Demographics
NPI:1558351445
Name:KENNEDY, MICHAEL T (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:T
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:PO BOX 166
Mailing Address - Street 2:
Mailing Address - City:ST ALBANS
Mailing Address - State:VT
Mailing Address - Zip Code:05478-0166
Mailing Address - Country:US
Mailing Address - Phone:802-524-2168
Mailing Address - Fax:802-524-0411
Practice Address - Street 1:148 FAIRFIELD ST
Practice Address - Street 2:
Practice Address - City:ST ALBANS
Practice Address - State:VT
Practice Address - Zip Code:05478-1729
Practice Address - Country:US
Practice Address - Phone:802-524-2168
Practice Address - Fax:802-524-0411
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0420010044174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT28637OtherBLUE CROSS BLUE SHIELD
VT5269401OtherFAHC PREFERRED
VT0VN2288Medicaid
VT02V202OtherMVP HEALTH CARE
VT02V202OtherMVP HEALTH CARE
VT0VN2288Medicaid