Provider Demographics
NPI:1861450439
Name:KENNEDY, PATRICIA RAE (MD)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:RAE
Last Name:KENNEDY
Suffix:
Gender:F
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 1368
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12201-1368
Mailing Address - Country:US
Mailing Address - Phone:518-580-2170
Mailing Address - Fax:518-580-2171
Practice Address - Street 1:6 MEDICAL DRIVE
Practice Address - Street 2:SUITE 202
Practice Address - City:MALTA
Practice Address - State:NY
Practice Address - Zip Code:12020
Practice Address - Country:US
Practice Address - Phone:518-580-2170
Practice Address - Fax:518-580-2171
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY176536208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000386171OtherANTHEM PIN
IN200800120Medicaid
NY02623274Medicaid
F71506Medicare UPIN
IN233690AMedicare PIN
IN200800120Medicaid
INP00350791Medicare PIN