Provider Demographics
NPI:1578689493
Name:KENNEDY, RICHARD D (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:D
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 1:96 INTEGRITY DR STE H
Mailing Address - Street 2:
Mailing Address - City:HEBRON
Mailing Address - State:OH
Mailing Address - Zip Code:43025-7013
Mailing Address - Country:US
Mailing Address - Phone:220-564-2100
Mailing Address - Fax:220-564-2101
Practice Address - Street 1:96 INTEGRITY DR STE H
Practice Address - Street 2:
Practice Address - City:HEBRON
Practice Address - State:OH
Practice Address - Zip Code:43025-7013
Practice Address - Country:US
Practice Address - Phone:220-564-2100
Practice Address - Fax:220-564-2101
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2018-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.089392207QG0300X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000474321OtherOHIO MEDICAID UNISON
OH2728632OtherOH MEDICAID MOLINA
OH2728632Medicaid
OH310917085274OtherOH MEDICAID CARESOURCE
WV3810022215Medicaid
OH2728632OtherOH MEDICAID MOLINA
OHH051921Medicare PIN