Provider Demographics
NPI:1700957123
Name:KENNEDY, STEPHEN D (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:D
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1694 W LOGANSPORT RD
Mailing Address - Street 2:
Mailing Address - City:PERU
Mailing Address - State:IN
Mailing Address - Zip Code:46970-3149
Mailing Address - Country:US
Mailing Address - Phone:765-472-2812
Mailing Address - Fax:765-472-2970
Practice Address - Street 1:1694 W LOGANSPORT RD
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IN
Practice Address - Zip Code:46970-3149
Practice Address - Country:US
Practice Address - Phone:765-472-2812
Practice Address - Fax:765-472-2970
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01044433207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200091180 BMedicaid
INP01418893OtherRR MEDICARE