Provider Demographics
NPI:1881780807
Name:KENNEDY, MARIE D (PAC)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:D
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 35100
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59107-5100
Mailing Address - Country:US
Mailing Address - Phone:406-238-2500
Mailing Address - Fax:
Practice Address - Street 1:2675 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59102-6686
Practice Address - Country:US
Practice Address - Phone:406-238-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT159363A00000X
MTMED-PAC-LIC-159363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT000091603OtherBCBS PIN
MT0432769OtherMDCD PIN
MT970007661Medicare PIN
MT000080938Medicare PIN
MT000081893Medicare PIN
MT000091603OtherBCBS PIN
MTS36212Medicare UPIN