Basic Information
| Provider Information | |||||||||
| NPI: | 1740273010 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KENNEDY | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | PETER | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 26901 BEAUMONT BLVD STE 3D | ||||||||
| Address2: | |||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480333849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9475221863 | ||||||||
| FaxNumber: | 9475220307 | ||||||||
| Practice Location | |||||||||
| Address1: | 4900 MERCURY DR STE 201 | ||||||||
| Address2: | |||||||||
| City: | DEARBORN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481262947 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3135835440 | ||||||||
| FaxNumber: | 3135835542 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2005 | ||||||||
| LastUpdateDate: | 10/23/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 4301073494 | MI | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | MD428982 | PA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 1016397670002 | 05 | PA | MEDICAID |