Provider Demographics
NPI:1972514800
Name:KENNEDY, MICHAEL PATRICK (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:PATRICK
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 SAINT CHARLES ST
Mailing Address - Street 2:
Mailing Address - City:CARENCRO
Mailing Address - State:LA
Mailing Address - Zip Code:70520-0000
Mailing Address - Country:US
Mailing Address - Phone:337-886-1200
Mailing Address - Fax:337-886-0919
Practice Address - Street 1:111 SAINT CHARLES ST
Practice Address - Street 2:
Practice Address - City:CARENCRO
Practice Address - State:LA
Practice Address - Zip Code:70520-4004
Practice Address - Country:US
Practice Address - Phone:337-886-1200
Practice Address - Fax:337-886-0919
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2009-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD018238207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
7299329OtherAETNA
10990532OtherCAQH
LA1377104Medicaid
LAF4181OtherBLUE CROSS
10990532OtherCAQH
7299329OtherAETNA