Provider Demographics
NPI:1568455194
Name:KENNEDY, KATHLEEN A (MD)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:A
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 WOODLAND ST
Mailing Address - Street 2:STE 47
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06105-2372
Mailing Address - Country:US
Mailing Address - Phone:860-525-4005
Mailing Address - Fax:860-525-4839
Practice Address - Street 1:19 WOODLAND ST
Practice Address - Street 2:STE 35
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06105-2372
Practice Address - Country:US
Practice Address - Phone:860-525-1234
Practice Address - Fax:860-278-8782
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT026843207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
060052425OtherRAILROAD MEDICARE
CTHAS544OtherOXFORD
CT001268433Medicaid
0004244738OtherAETNA
2083418OtherAETNA
00126843301OtherANTHEM BCBS
010026843CT03OtherANTHEM BCBS
CT708620OtherCONNECTICARE
CTHAS544OtherOXFORD
060052425OtherRAILROAD MEDICARE
CTOV4112OtherHEALTH NET