Provider Demographics
NPI:1811195282
Name:KENNEDY, RUTH C
Entity Type:Individual
Prefix:
First Name:RUTH
Middle Name:C
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:RUTH
Other - Middle Name:E
Other - Last Name:CARTER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:1617 DEVON DR
Mailing Address - Street 2:
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034-4142
Mailing Address - Country:US
Mailing Address - Phone:817-283-4862
Mailing Address - Fax:817-571-6519
Practice Address - Street 1:1617 DEVON DR
Practice Address - Street 2:
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034-4142
Practice Address - Country:US
Practice Address - Phone:817-283-4862
Practice Address - Fax:817-571-6519
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-06
Last Update Date:2016-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD1398207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP000C8805Medicaid
097268Medicare UPIN
TXP000C8805Medicaid