Provider Demographics
NPI:1821076019
Name:KENNEDY, ALFRED PARKER JR (MD)
Entity Type:Individual
Prefix:
First Name:ALFRED
Middle Name:PARKER
Last Name:KENNEDY
Suffix:JR
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 1:100 N ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-4903
Mailing Address - Country:US
Mailing Address - Phone:570-271-6144
Mailing Address - Fax:
Practice Address - Street 1:100 N ACADEMY AVE
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:PA
Practice Address - Zip Code:17822-2219
Practice Address - Country:US
Practice Address - Phone:570-214-7967
Practice Address - Fax:570-214-2800
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD388902086S0120X
PAMD048614L2086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN5440421Medicaid
F40200Medicare UPIN