Provider Demographics
NPI:1841288701
Name:KENNEDY, ERIC ALAN (PA-C)
Entity type:Individual
Prefix:MR
First Name:ERIC
Middle Name:ALAN
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 JOHN ST
Mailing Address - Street 2:BOX 42
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-5341
Mailing Address - Country:US
Mailing Address - Phone:269-341-7806
Mailing Address - Fax:269-341-8743
Practice Address - Street 1:52375 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MATTAWAN
Practice Address - State:MI
Practice Address - Zip Code:49071-9332
Practice Address - Country:US
Practice Address - Phone:269-668-3348
Practice Address - Fax:269-668-7702
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2013-01-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5601002670363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1841288701Medicaid
MI700H060020OtherBCBSM
MIP44984Medicare UPIN
MIH06012028Medicare PIN