Provider Demographics
NPI:1700902988
Name:KENNEDY, GERALD ANTHONY (DC)
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:ANTHONY
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1632 LEBANON AVE
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62221-2466
Mailing Address - Country:US
Mailing Address - Phone:618-310-1499
Mailing Address - Fax:314-558-4396
Practice Address - Street 1:1632 LEBANON AVE
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62221-2466
Practice Address - Country:US
Practice Address - Phone:618-310-1499
Practice Address - Fax:314-558-4396
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209876Medicare ID - Type Unspecified
IL8257Medicare UPIN