Provider Demographics
NPI:1669570511
Name:KENNEDY, MICHAEL SCOTT (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:SCOTT
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:100 MICHIGAN ST NE # MC845
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:616-486-6790
Mailing Address - Fax:
Practice Address - Street 1:5 N ATKINSON DR
Practice Address - Street 2:SUITE 200
Practice Address - City:LUDINGTON
Practice Address - State:MI
Practice Address - Zip Code:49431-2918
Practice Address - Country:US
Practice Address - Phone:231-843-2664
Practice Address - Fax:231-845-6873
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MIMK042735207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIA74378Medicare UPIN
MI1532820Medicaid
MI2005310232OtherBLUE CROSS BLUE SHIELD
MI2005310232OtherBLUE CROSS BLUE SHIELD