Provider Demographics
NPI:1881659845
Name:KENNEDY, RICHARD GORDON (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:GORDON
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 1:1835 FAIRPORT NINE MILE POINT RD
Mailing Address - Street 2:STE 100
Mailing Address - City:PENFIELD
Mailing Address - State:NY
Mailing Address - Zip Code:14526-1903
Mailing Address - Country:US
Mailing Address - Phone:585-758-0777
Mailing Address - Fax:585-388-9079
Practice Address - Street 1:1835 FAIRPORT NINE MILE POINT RD
Practice Address - Street 2:STE 100
Practice Address - City:PENFIELD
Practice Address - State:NY
Practice Address - Zip Code:14526-1903
Practice Address - Country:US
Practice Address - Phone:585-758-0777
Practice Address - Fax:585-388-9079
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2016-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY167256207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01159993Medicaid
NYJ400277140Medicare PIN
NY01159993Medicaid