Provider Demographics
NPI:1295767614
Name:KENNEDY, MICHAEL GERALD (MD)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:GERALD
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 1:6 UNION ST
Mailing Address - Street 2:
Mailing Address - City:NATICK
Mailing Address - State:MA
Mailing Address - Zip Code:01760-4784
Mailing Address - Country:US
Mailing Address - Phone:508-655-5115
Mailing Address - Fax:508-650-9351
Practice Address - Street 1:6 UNION ST
Practice Address - Street 2:
Practice Address - City:NATICK
Practice Address - State:MA
Practice Address - Zip Code:01760-4784
Practice Address - Country:US
Practice Address - Phone:508-655-5115
Practice Address - Fax:508-650-9351
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA45134207XX0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Trauma
Provider Identifiers
StateIdentifier IDID TypeIssuer
B32117Medicare ID - Type Unspecified
B87289Medicare UPIN