Provider Demographics
NPI:1982778486
Name:KENNEDY, MICHAEL (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 SOUTHDOWN RD
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-2538
Mailing Address - Country:US
Mailing Address - Phone:631-923-2139
Mailing Address - Fax:631-923-2140
Practice Address - Street 1:17 SOUTHDOWN RD
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-2538
Practice Address - Country:US
Practice Address - Phone:631-923-2139
Practice Address - Fax:631-923-2140
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY171806207P00000X
PAOS-006765-E207P00000X
NC02524207P00000X
CA20A18353207P00000X
SC420207PS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PS0010XAllopathic & Osteopathic PhysiciansEmergency MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01071058Medicaid
NY01071058Medicaid
NYE59948Medicare UPIN