Provider Demographics
NPI:1912926486
Name:KENNEDY, KAREN MARSHELIA (MD)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:MARSHELIA
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 STATE ST SE
Mailing Address - Street 2:STE 221
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1246 MADISON SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49507
Practice Address - Country:US
Practice Address - Phone:616-685-8300
Practice Address - Fax:616-685-8322
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY224994207Q00000X
MI4301091353207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
114348OtherBOARD CERTIFICATE #
NY02320634Medicaid
H58122Medicare UPIN
NY02320634Medicaid
MIOP32930343Medicare PIN