Provider Demographics
NPI:1710984216
Name:KENNEDY III, CHARLES THOMAS (DC)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:THOMAS
Last Name:KENNEDY III
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1578 EASTON AVENUE
Mailing Address - Street 2:
Mailing Address - City:BETHLEHEM
Mailing Address - State:PA
Mailing Address - Zip Code:18017
Mailing Address - Country:US
Mailing Address - Phone:610-866-4440
Mailing Address - Fax:610-866-5671
Practice Address - Street 1:1578 EASTON AVENUE
Practice Address - Street 2:
Practice Address - City:BETHLEHEM
Practice Address - State:PA
Practice Address - Zip Code:18017
Practice Address - Country:US
Practice Address - Phone:610-866-4440
Practice Address - Fax:610-866-5671
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2013-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC003479L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0015429890005Medicaid
PA0266570OtherBLUE CROSS
PA00278910OtherBLUE SHIELD
PA0015429890005Medicaid
PA0266570OtherBLUE CROSS