Provider Demographics
NPI:1295933000
Name:COLLEEN KENNEDY DO PC
Entity type:Organization
Organization Name:COLLEEN KENNEDY DO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING SUPERVISOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JOANNE
Authorized Official - Middle Name:S
Authorized Official - Last Name:GOODRICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-299-1892
Mailing Address - Street 1:75 BARCLAY CIRCLE
Mailing Address - Street 2:SUITE 225
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48307-4572
Mailing Address - Country:US
Mailing Address - Phone:248-299-1892
Mailing Address - Fax:248-299-1396
Practice Address - Street 1:75 BARCLAY CIRCLE
Practice Address - Street 2:SUITE 225
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48307-4572
Practice Address - Country:US
Practice Address - Phone:248-299-1892
Practice Address - Fax:248-299-1396
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-03
Last Update Date:2010-12-16
Deactivation Date:2007-11-23
Deactivation Code:
Reactivation Date:2010-10-06
Provider Licenses
StateLicense IDTaxonomies
MI5101012334207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N22720Medicare ID - Type Unspecified
MIG58126Medicare UPIN