Provider Demographics
NPI:1609817618
Name:KENNEDY, PHILLIP S (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:S
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 2510
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-2510
Mailing Address - Country:US
Mailing Address - Phone:706-922-8274
Mailing Address - Fax:706-922-6695
Practice Address - Street 1:3614 D J DEWEY GRAY CIRCLE
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909
Practice Address - Country:US
Practice Address - Phone:706-868-7380
Practice Address - Fax:706-868-7223
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA043985207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA336986OtherWELLCARE
SCG43985Medicaid
GA043985OtherLICENSE
GA00793922AMedicaid
GA10056165OtherAMERIGROUP
GACH0654OtherRR MEDICARE GROUP PIN
GA10056165OtherAMERIGROUP