Provider Demographics
NPI:1902075435
Name:KENNEDY, EDMUND (MD)
Entity Type:Individual
Prefix:
First Name:EDMUND
Middle Name:
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:PO BOX 402319
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-2319
Mailing Address - Country:US
Mailing Address - Phone:479-709-7399
Mailing Address - Fax:479-709-7053
Practice Address - Street 1:1501 S WALDRON RD
Practice Address - Street 2:STE 107
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-2574
Practice Address - Country:US
Practice Address - Phone:479-573-7980
Practice Address - Fax:479-573-7981
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-28
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR3286207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100055840AMedicaid
AR107739001Medicaid
OK100055840AMedicaid