Provider Demographics
NPI:1699774448
Name:KENNEDY, GEORGE MITCHELL (M D)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:MITCHELL
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:463 JESSING TRL
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43235-1474
Mailing Address - Country:US
Mailing Address - Phone:614-885-5578
Mailing Address - Fax:
Practice Address - Street 1:3545 OLENTANGY RIVER RD
Practice Address - Street 2:SUITE 525
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-3907
Practice Address - Country:US
Practice Address - Phone:614-261-1900
Practice Address - Fax:614-261-7538
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35065046208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0919966Medicaid
0739291Medicare PIN
F56008Medicare UPIN