Provider Demographics
NPI:1851579403
Name:ROGER M KENNEDY OPTICIAN
Entity Type:Organization
Organization Name:ROGER M KENNEDY OPTICIAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SON OF ROGER
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:M
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-742-3597
Mailing Address - Street 1:1829 COTTMAN AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19111-3846
Mailing Address - Country:US
Mailing Address - Phone:215-742-3597
Mailing Address - Fax:267-345-0036
Practice Address - Street 1:1829 COTTMAN AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19111-3846
Practice Address - Country:US
Practice Address - Phone:215-742-3597
Practice Address - Fax:267-345-0036
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-06
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0538390001Medicare NSC