Provider Demographics
NPI:1295707784
Name:KENNEDY, ROBERT G (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:G
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 1:724 S MASON ST MSC 7901
Mailing Address - Street 2:
Mailing Address - City:HARRISONBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22807-5705
Mailing Address - Country:US
Mailing Address - Phone:540-568-5728
Mailing Address - Fax:
Practice Address - Street 1:724 S MASON ST MSC 7901
Practice Address - Street 2:
Practice Address - City:HARRISONBURG
Practice Address - State:VA
Practice Address - Zip Code:22807-5705
Practice Address - Country:US
Practice Address - Phone:540-568-5728
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2023-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC161212207Q00000X
VA0101238231207Q00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVVE6439975OtherMEDICARE PTAN-AHWI
VA179367OtherANTHEM
VA5630042OtherFIRST HEALTH
VA010160367OtherVA PREMIER
VA010160367Medicaid
VA97250OtherOPTIMA
VA315335OtherSOUTHERN HEALTH
VA010160367Medicaid
VA010160367OtherVA PREMIER
VA007654A48Medicare ID - Type Unspecified
VAC06248Medicare PIN
VAP00238884Medicare PIN