Provider Demographics
NPI:1548392962
Name:KENNEDY, MICHAEL WESLEY (PT, MS)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:WESLEY
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:PT, MS
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Other - Credentials:
Mailing Address - Street 1:PO BOX 51322
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42102-5622
Mailing Address - Country:US
Mailing Address - Phone:270-777-9283
Mailing Address - Fax:270-777-1550
Practice Address - Street 1:181 W PROFESSIONAL PARK CT
Practice Address - Street 2:SUITE 1
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-3250
Practice Address - Country:US
Practice Address - Phone:270-843-5300
Practice Address - Fax:270-843-5383
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2014-05-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY003567225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0719402Medicare PIN