Provider Demographics
NPI:1356586853
Name:KENNEDY, SUSAN MARIE (DO)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:MARIE
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:MRS
Other - First Name:SUSAN
Other - Middle Name:K
Other - Last Name:YEAGLEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1185 S LEOPARD RD
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:PA
Mailing Address - Zip Code:19312-2028
Mailing Address - Country:US
Mailing Address - Phone:610-651-0355
Mailing Address - Fax:610-651-7666
Practice Address - Street 1:1185 S LEOPARD RD
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:PA
Practice Address - Zip Code:19312-2028
Practice Address - Country:US
Practice Address - Phone:610-651-0355
Practice Address - Fax:610-651-7666
Is Sole Proprietor?:No
Enumeration Date:2008-12-11
Last Update Date:2008-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA002010207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine