Provider Demographics
NPI:1659492858
Name:MICHAEL G KENNEDY MD PC
Entity type:Organization
Organization Name:MICHAEL G KENNEDY MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:G
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:508-655-5115
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA45134207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
B32117Medicare ID - Type Unspecified
B87289Medicare UPIN