Provider Demographics
NPI:1013127281
Name:KENNEDY EYE ASSOCIATES
Entity Type:Organization
Organization Name:KENNEDY EYE ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:B
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:OD, FAAO
Authorized Official - Phone:651-488-6771
Mailing Address - Street 1:1790 LEXINGTON AVE N
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55113-6167
Mailing Address - Country:US
Mailing Address - Phone:651-488-6771
Mailing Address - Fax:651-488-5576
Practice Address - Street 1:1790 LEXINGTON AVE N
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55113-6167
Practice Address - Country:US
Practice Address - Phone:651-488-6771
Practice Address - Fax:651-488-5576
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC01453Medicare ID - Type Unspecified
MN0383260001Medicare NSC