Provider Demographics
NPI:1629160379
Name:KENNEDY, MARY JO (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY JO
Middle Name:
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 1:215 E 95TH ST
Mailing Address - Street 2:SUITE M, FIRST FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10128-4077
Mailing Address - Country:US
Mailing Address - Phone:212-996-8000
Mailing Address - Fax:212-348-1260
Practice Address - Street 1:215 E 95TH ST
Practice Address - Street 2:SUITE M, FIRST FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10128-4077
Practice Address - Country:US
Practice Address - Phone:212-996-8000
Practice Address - Fax:212-348-1260
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2010-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY152726207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY669661Medicaid
NY669661Medicaid