Provider Demographics
NPI:1740220789
Name:KENNEDY, ROBERT (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 W EAU GALLIE BLVD
Mailing Address - Street 2:200
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-3165
Mailing Address - Country:US
Mailing Address - Phone:321-253-2900
Mailing Address - Fax:321-435-0100
Practice Address - Street 1:415 S WICKHAM RD
Practice Address - Street 2:
Practice Address - City:WEST MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-1137
Practice Address - Country:US
Practice Address - Phone:321-400-1220
Practice Address - Fax:321-241-3000
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME818802085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL273810400Medicaid
FL273810400Medicaid
FLU6217ZMedicare PIN