1629188941 NPI number — STEPHEN KENNEDY, MD, INC.

Table of content: (NPI 1629188941)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629188941 NPI number — STEPHEN KENNEDY, MD, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STEPHEN KENNEDY, MD, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1629188941
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/09/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9300 W STOCKTON BLVD
Provider Second Line Business Mailing Address:
SUITE # 104
Provider Business Mailing Address City Name:
ELK GROVE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95758-8070
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-691-2069
Provider Business Mailing Address Fax Number:
916-691-2065

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9300 W STOCKTON BLVD
Provider Second Line Business Practice Location Address:
SUITE # 104
Provider Business Practice Location Address City Name:
ELK GROVE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95758-8070
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-691-2069
Provider Business Practice Location Address Fax Number:
916-691-2065
Provider Enumeration Date:
08/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KENNEDY
Authorized Official First Name:
STEPHEN
Authorized Official Middle Name:
WILLIAM
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
916-691-2069

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  A 86061 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1689668279 . This is a "MEDICARE NPI - INDIVIDUAL FOR DR. STEPHEN KENNEDY" identifier . This identifiers is of the category "OTHER".




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