Provider Demographics
NPI:1851746135
Name:KENNEDY, ELIJAH (MD)
Entity Type:Individual
Prefix:
First Name:ELIJAH
Middle Name:
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 1:5870 HIATUS RD
Mailing Address - Street 2:
Mailing Address - City:TAMARAC
Mailing Address - State:FL
Mailing Address - Zip Code:33321-6424
Mailing Address - Country:US
Mailing Address - Phone:800-424-3672
Mailing Address - Fax:954-377-3042
Practice Address - Street 1:7727 LAKE UNDERHILL RD
Practice Address - Street 2:DEPARTMENT OF EMERGENCY MEDICINE
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32822-8224
Practice Address - Country:US
Practice Address - Phone:407-303-6413
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-25
Last Update Date:2019-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME136445207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program