Provider Demographics
NPI:1205051265
Name:DAVID G. KENNEDY A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:DAVID G. KENNEDY A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:G
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-743-0330
Mailing Address - Street 1:PO BOX 11795
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63105-0595
Mailing Address - Country:US
Mailing Address - Phone:314-743-0330
Mailing Address - Fax:314-743-0339
Practice Address - Street 1:3009 N BALLAS RD
Practice Address - Street 2:SUITE 269C
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-2322
Practice Address - Country:US
Practice Address - Phone:314-743-0330
Practice Address - Fax:314-743-0339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2014-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000001752Medicare PIN