Provider Demographics
NPI:1639100035
Name:KENNEDYE, JAMES R (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:R
Last Name:KENNEDYE
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 1:908 FOX HILL DR
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-7317
Mailing Address - Country:US
Mailing Address - Phone:405-330-8982
Mailing Address - Fax:
Practice Address - Street 1:908 FOX HILL DR
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-7317
Practice Address - Country:US
Practice Address - Phone:405-330-8982
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2009-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK22846207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100848010BMedicaid
MO205291107Medicaid
MO205291107Medicaid
H36122Medicare UPIN
OK248604807Medicare PIN
OK100848010BMedicaid