Provider Demographics
NPI:1982665303
Name:KENNEDY, CHRISTOPHER R (MD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:R
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 1:4201 ST ANTOINE ST
Mailing Address - Street 2:SUITE 3 R
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2153
Mailing Address - Country:US
Mailing Address - Phone:313-745-3330
Mailing Address - Fax:
Practice Address - Street 1:4201 ST ANTOINE ST
Practice Address - Street 2:SUITE 3 R
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2153
Practice Address - Country:US
Practice Address - Phone:313-745-3330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301076517207PE0004X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104527378Medicaid
MI104527387Medicaid
MICK076517OtherBC/BS OF MI
MI104592910Medicaid
MI104527387Medicaid
MII00104Medicare UPIN