Provider Demographics
NPI:1649346081
Name:KENNEDY, MICHAEL DUSTIN (DO)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DUSTIN
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 GIBNER RD STE 1
Mailing Address - Street 2:
Mailing Address - City:CARLISLE BARRACKS
Mailing Address - State:PA
Mailing Address - Zip Code:17013-5086
Mailing Address - Country:US
Mailing Address - Phone:717-245-3400
Mailing Address - Fax:877-846-6967
Practice Address - Street 1:450 GIBNER RD STE 1
Practice Address - Street 2:
Practice Address - City:CARLISLE BARRACKS
Practice Address - State:PA
Practice Address - Zip Code:17013-5086
Practice Address - Country:US
Practice Address - Phone:717-245-3400
Practice Address - Fax:877-846-6967
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-320207Q00000X
VA0102202027207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806642300Medicaid
VA1649346081Medicaid
ID1302755Medicare ID - Type Unspecified
VAH94344Medicare UPIN
VA1649346081Medicaid
VAINDIVIDUAL 00X578F01Medicare PIN