Provider Demographics
NPI:1659312841
Name:KENNEDY, MARY L (DO)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:L
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:6151 N MAIN STREET RD
Mailing Address - Street 2:
Mailing Address - City:WEBB CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64870-8189
Mailing Address - Country:US
Mailing Address - Phone:417-781-0408
Mailing Address - Fax:417-556-5377
Practice Address - Street 1:6151 N MAIN STREET RD
Practice Address - Street 2:
Practice Address - City:WEBB CITY
Practice Address - State:MO
Practice Address - Zip Code:64870-8189
Practice Address - Country:US
Practice Address - Phone:417-781-0408
Practice Address - Fax:417-556-5377
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2016-03-17
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MO2001016563207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP00800446OtherRAIL ROAD MEDICARE
MO1659312841Medicaid
MO1659312841Medicaid
MOMA2082046Medicare PIN