Provider Demographics
NPI:1609834860
Name:LESLIE A KENNEDY MD PA
Entity Type:Organization
Organization Name:LESLIE A KENNEDY MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:903-874-5512
Mailing Address - Street 1:1737 W 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:CORSICANA
Mailing Address - State:TX
Mailing Address - Zip Code:75110-4109
Mailing Address - Country:US
Mailing Address - Phone:903-874-5512
Mailing Address - Fax:903-872-1132
Practice Address - Street 1:3201 W HIGHWAY 22
Practice Address - Street 2:
Practice Address - City:CORSICANA
Practice Address - State:TX
Practice Address - Zip Code:75110-2450
Practice Address - Country:US
Practice Address - Phone:903-654-6822
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF35172085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00940KMedicare ID - Type Unspecified