Provider Demographics
NPI: | 1801004585 |
---|---|
Name: | KENNEDY, DANIEL WILLIAM (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | DANIEL |
Middle Name: | WILLIAM |
Last Name: | KENNEDY |
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: | PO BOX 948 |
Mailing Address - Street 2: | 2112 CHERRY VALLEY RD. |
Mailing Address - City: | NEWARK |
Mailing Address - State: | OH |
Mailing Address - Zip Code: | 43058-0948 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 740-522-3774 |
Mailing Address - Fax: | 740-522-2221 |
Practice Address - Street 1: | 1320 W MAIN ST |
Practice Address - Street 2: | |
Practice Address - City: | NEWARK |
Practice Address - State: | OH |
Practice Address - Zip Code: | 43055-1822 |
Practice Address - Country: | US |
Practice Address - Phone: | 740-348-4710 |
Practice Address - Fax: | 740-348-4740 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2007-05-18 |
Last Update Date: | 2014-11-13 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
OH | 57012390 | 2085R0202X |
OH | 35-090631 | 2085B0100X, 2085D0003X, 2085U0001X, 2085H0002X, 2085N0700X, 2085N0904X, 2085R0001X, 2085R0203X, 2085R0204X, 207U00000X, 207UN0903X, 207UN0901X, 207UN0902X |
OH | 35.090631 | 2085R0202X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 2085R0202X | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No | 2085B0100X | Allopathic & Osteopathic Physicians | Radiology | Body Imaging |
No | 2085D0003X | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Neuroimaging |
No | 2085U0001X | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound |
No | 2085H0002X | Allopathic & Osteopathic Physicians | Radiology | Hospice and Palliative Medicine |
No | 2085N0700X | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology |
No | 2085N0904X | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology |
No | 2085R0001X | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
No | 2085R0203X | Allopathic & Osteopathic Physicians | Radiology | Therapeutic Radiology |
No | 2085R0204X | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
No | 207U00000X | Allopathic & Osteopathic Physicians | Nuclear Medicine | |
No | 207UN0903X | Allopathic & Osteopathic Physicians | Nuclear Medicine | In Vivo & In Vitro Nuclear Medicine |
No | 207UN0901X | Allopathic & Osteopathic Physicians | Nuclear Medicine | Nuclear Cardiology |
No | 207UN0902X | Allopathic & Osteopathic Physicians | Nuclear Medicine | Nuclear Imaging & Therapy |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
OH | 3039198 | Medicaid | |
OH | P00880289 | Other | RAILROAD MEDICARE |
OH | P00880289 | Other | RAILROAD MEDICARE |