Provider Demographics
NPI:1902826274
Name:KENNEDY, EUGENE P (MD)
Entity Type:Individual
Prefix:DR
First Name:EUGENE
Middle Name:P
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 1:615 CHESTNUT ST
Mailing Address - Street 2:14TH FLOOR, CENTRAL ENROLLMENT
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19106-4404
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1100 WALNUT ST
Practice Address - Street 2:MOB, 5TH FLOOR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-5563
Practice Address - Country:US
Practice Address - Phone:215-955-6750
Practice Address - Fax:215-923-8222
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2011-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD428122208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0093815Medicaid
PA101509252Medicaid
NJ0093815Medicaid