Provider Demographics
NPI:1982694238
Name:KENNEDY, ROSEMARIE (MD)
Entity type:Individual
Prefix:
First Name:ROSEMARIE
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 S BALLENGER HWY
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-3638
Mailing Address - Country:US
Mailing Address - Phone:810-342-1000
Mailing Address - Fax:810-342-1590
Practice Address - Street 1:2420 OWEN RD
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-3417
Practice Address - Country:US
Practice Address - Phone:810-496-2500
Practice Address - Fax:810-629-0415
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301059498208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3502510121OtherBLUE CROSS BLUE SHIELD
MI1009249OtherMCLAREN HEALTH PLAN
MI4519017Medicaid
MI4941624003OtherCIGNA
MIH91967OtherHEALTH NET FEDERAL
MI1009249OtherHEALTH ADVANTAGE NETWORK
MIH91967OtherHEALTH ALLIANCE PLAN
MIP00076880/CD3612OtherMETRAHEALTH
MI0995963OtherHEALTH PLUS OF MI
MA5072036OtherAETNA
MIC5452OtherMCARE
MIP00076880/CD3612OtherMETRAHEALTH
MI4519017Medicaid