Basic Information
| Provider Information | |||||||||
| NPI: | 1801004585 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KENNEDY | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | WILLIAM | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 948 | ||||||||
| Address2: | 2112 CHERRY VALLEY RD. | ||||||||
| City: | NEWARK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430580948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7405223774 | ||||||||
| FaxNumber: | 7405222221 | ||||||||
| Practice Location | |||||||||
| Address1: | 1320 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430551822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403484710 | ||||||||
| FaxNumber: | 7403484740 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2007 | ||||||||
| LastUpdateDate: | 11/13/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 57012390 | OH | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085B0100X | 35-090631 | OH | N | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 2085D0003X | 35-090631 | OH | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Neuroimaging | 2085U0001X | 35-090631 | OH | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound | 2085H0002X | 35-090631 | OH | N | Allopathic & Osteopathic Physicians | Radiology | Hospice and Palliative Medicine | 2085N0700X | 35-090631 | OH | N | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085N0904X | 35-090631 | OH | N | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | 2085R0001X | 35-090631 | OH | N | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 2085R0203X | 35-090631 | OH | N | Allopathic & Osteopathic Physicians | Radiology | Therapeutic Radiology | 2085R0204X | 35-090631 | OH | N | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 207U00000X | 35-090631 | OH | N | Allopathic & Osteopathic Physicians | Nuclear Medicine | 207UN0903X | 35-090631 | OH | N | Allopathic & Osteopathic Physicians | Nuclear Medicine | In Vivo & In Vitro Nuclear Medicine | 207UN0901X | 35-090631 | OH | N | Allopathic & Osteopathic Physicians | Nuclear Medicine | Nuclear Cardiology | 207UN0902X | 35-090631 | OH | N | Allopathic & Osteopathic Physicians | Nuclear Medicine | Nuclear Imaging & Therapy | 2085R0202X | 35.090631 | OH | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 3039198 | 05 | OH | MEDICAID | P00880289 | 01 | OH | RAILROAD MEDICARE | OTHER |