Basic Information
Provider Information
NPI: 1003010984
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: KENNEDY
FirstName: STEPHEN
MiddleName: ROGERS
NamePrefix: DR.
NameSuffix:  
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 501 6TH AVE S
Address2: BOX 6941
City: ST PETERSBURG
State: FL
PostalCode: 337014634
CountryCode: US
TelephoneNumber: 7277674429
FaxNumber: 7277674970
Practice Location
Address1: 501 6TH AVE S
Address2:  
City: ST PETERSBURG
State: FL
PostalCode: 337014634
CountryCode: US
TelephoneNumber: 7277674243
FaxNumber: 7277678612
Other Information
ProviderEnumerationDate: 06/13/2007
LastUpdateDate: 03/03/2010
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
208000000XME98966FLY Allopathic & Osteopathic PhysiciansPediatrics 
208M00000XME98966FLN Allopathic & Osteopathic PhysiciansHospitalist 

ID Information
IDTypeStateIssuerDescription
27832910005FL MEDICAID
8103901FLBLUE CROSS/BLUE SHIELDOTHER
907206301FLAETNAOTHER
51224801FLSTAYWELL/HEALTHEASEOTHER
30919601FLAVMEDOTHER


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